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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Coriiplete in Triplicate)' i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This 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 Local Health District. Job Address Size M Owner's Name J l ' '��`" Address •� ` Phone i t��til T �� License NaPhont:.0 Contractor �' r Adtlress ] , !'- TYPE OF WELL/PUMP: NEW WELL —WELL"REPLACEMENT.❑, ""'°""'.DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ _____r l$TANCE TO NEAREST: SEPTIC TANK .. SEWER LINES ' DISPOSAL FLD. PROP. tINE 4 - FOUNDATION 76— AGRICULTURE WELL OTHER WELL PITS/SUMPS —. INTENDED USE ,.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial < pen ottom ❑ Manteca n Dia. of-Well Excavation s Dia. of Well Casing yr�� estic/Private ' ❑ Gravel Pack ❑ Tracy Type of'Casing ✓ ! Specifications �1.�"r ("1 Public (J Ofher ❑ Delta Depth of Grout Seat Typ of Grout i I Irrigation Approx. Depth l 1 astern Surf ce Seal Installed by - Repair Work Done; ❑ `/Type of Pump H.P. State Work Done { Well Destruction _❑ Well Diameter Sealing Material (top 501 Depth �� Filler Material (Below 50'1 ' r'+ — r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i f Water table depth f M Character of soil to a depth of 3 feet: -��"�'�"`� ,j p SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, 171 Method of Disposal t Distance to nearest: Well foundation Property.Line t' LEACHING LINE ❑ o. & Length of lines Total length/size FILTER BED ❑:'!Distance to nearest: Well Foundati6n— _ a Property tine r - SEEPAGE PITS :I I Depth Size Number'_• SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E) I hereby certify that.) 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- ition•iaw4s of'California." The�appficant mu call for all required inspections. ete drawing on reverse side. Signed X - Title: Date: 1 r t F DEFT tTWENT USE ONLY Application Accepted by Ck AA Date / ea Pit or Grout Inspection by Date//d Final Inspection by Date �� x r Additional Comments: ❑ Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 I EFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. � INFO �l1s�. c�p--- �+" +..EH 13-241REV-i iK 5f z �� t+vV �(✓J -C�� & J �Q 2} y'7 [; EH 14.28 "`�� IJ