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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG (Complete in Triplicate) ri TI,is application is Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor insta �tRf ; '��t��ryiW San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weRJpump and the��IM4,l tt Local Health District. 11 V Lot Size PM Job Address .I Address 1t��l l/1 ,CL3-y � - Phone 2 "0f yl— Owner's Name IAddress)r f�� 1['i't ''�"`�'� ` C" License No. Phone Contractor _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )- DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial LJ open Bottom ❑ Manteca Dia. of Well Excavation r Specifications + L LDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout f-1Public I-] OtherI 1-7 Delta Depth of Grout Seal - I I Irrigation Approx..Depth l I Eastern L ,urface Seal Installed by - + H P ate Work Done Repair Work Done l� Type of Pump IJP r. Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION i I (Noseptic hie system feetitted if public sewer is availabf� I I Installation will serve: Residence_i Commercial— Other Number of living units: Number of bedrooms I I ` 'r Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ,❑t,TYpe/Mf§1 _ ..-- +... Method of Disposal PKG. TREATMENT PLT. ❑"- f� a Distance to nearest: Well Foundation Property Lrne LEACHING LINE Cl No. & Length of lines Total length/size 5 Property Line FILTER BED ❑ Distance,� nearest: Well Foundation P Y Size Number SEEPAGE PITS I I Depth SUMPS C) Distance to nearest: WeN Foundation Property Line . DISPOSAL PONDS L7-w — -+ »F -- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f all required inspections. Complete drawing on rreverse side. �e Date: 2 I Signed X Title: _t r ? FOR DEPARTMENT USE ONLY Application Accepted by Date Area r Pit or Grout Inspection by Date Final Inspection by Date 4 ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED C H RECEIVED BY DATE PERMIT NO. INFO I + EH 13.24 MET I/r+5f EH 14-2e t �