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APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA UL 17 Telephone (209) 466-6781 " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LOM (Complete in Triplicate) iLTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. L 6.�3-64 77 4r L Job Address Ci Lot Size PM Owner's Name Address Phone A 2-40j Contractor's Name License No. 5 �3Phone " l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,F_LD. -PROP--_LINE -- �► '--=� " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' ' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. DepA ❑ Eastern §urface Seal Installed by Repair Work Done I Type of Pump H.P. R 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 y Depth Filler Material IBelow 501 f �- ' r✓ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is Z v available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: P Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y PKG. TREATMENT PLT. ❑ L 2 Method of Disposal p I Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, —[E 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. 1113 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, l 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 st c ll II required inspections. Complete drawing on r side. Signed X Title: , _ Date: FOR DEPA MENT USE ONLY 1 Application Accepted by / Date Area Pit or Grout Inspection by Date Final Inspection by ate L6 L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealt ermit/Services 1601 E. Hazelton Ave.'P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K# RECEIVED BY DATE PERMIT'NO. INFO (� l + EH 1324 MEV.10/83) S 4-Y,y 13 L ` / EH 14-28