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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tv;v;;r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Tfiis application is e or No..1662 for wen/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag Local Health District. * �+ Job Address `y�'Cit/ljl r G Lot Size PNI.: ----- it r-- Owner's Name- -- "" ""' "Address �� --.__.... - Phone f i _ ' ��' 7 License No 2%-' Phone Contractor ` Address TYPE OF WELL/PUMP: NEW WELL ❑ +x WELL REPLACEMENT ❑ DESTRUCTION ❑ 't PUMP INSTALLATION 171 "r w SYSTEM REPAIR ElOTHER ❑ 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 ❑ Industrial ❑ Open 9ottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑•Domestic/Private" ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J ❑ Public J- �- 13 Other .1 ❑ Delta Depth of Grout-Seal Type of Grout C1 Irrigation ---Approx.,.,Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump j H.P. State Work Done -- I Well Destruction ❑ Well Diameter Sealing Material (top 501' Depth Filler Material (Below 501• " ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic-system-permitted-if--public-sewer-is i available within 200 feet.) Installation will serve: Residence *"- Commercial— Others L--� Number of living units: Number obedrooms Character of soil to a dep)h of 3 fe Water-,table depth SEPTIC TANK 01 Type/Mfg j Capacity f oC No: Compartments 7- ' , Method of Disposal r PKG. TREATMENT PLT. ❑ - Distance to nearest: ,�,Well I itG + Foundation Property Line _ 1, I LEACHING LINE No. & Length of lines "i 'o Total length/size FILTER BED ID Distance to nearest: Well 120 t �^ Foundation i t) , Property,Line J � � 'SEEPAGE PITS U9/ Depth Size '� r SUMPS O Distance to nearest: Well_ n' ' - Foundation 1 8 't Property Line " DISPOSAL PONDS ❑ 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. I 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 tail for all required i a_ls coons. Complete drawing on reverse side. Signed Title: Date: /? - FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by A Date Final Inspection by Date Additional Comments: ❑ Stk 466 781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEE) CASH RECEIVED BY DATE PERMIT"NO. INFO {��/} Q�, J�JY! + EH1 24(REV.1/a5) -70 V0 - 'W - ��'`+ Yo Six EH 1428 }