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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 (Complete in Triplicate) 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 Address6zz� f�!7'�C.�' ,,",_ Cites i� Lot Size Qo PM Owner's Name A /07 6 4 5; Phon Address ,•� 47-Contractor sName— Z—_ W License No_ � 1 / Phone TYPE OF WELL/PUMP: NEW WELL C WELOWEPLACEMENT ❑ DESTRUCTION D ' 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 PROBLE4 REAT 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 fl Delta Depth of Gro t Seal Type of Grout ❑ Irrigation --Approx. Depth C7 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done' Well Destruction ❑ Well Diameter Sealind-Material (top 501 yf� Depth t filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONI❑ REPAIR/ADDITION DESTRUCTION ❑ iNo septic system permitted if public sewer is r • ' available within 200 feet.) Installation will serve: Residence _ C� ommercia _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tall .depth SEPTIC TANK ❑ Type/Mfg Capacity { No. Co part'nents PKG. TREATMENT PLT. ❑ f it '* Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING1INyE o & Length of lines4 , , — Total length/size FILTER d t BED ❑�j Distance tot nearest: Well= Q` Foundation� Property Line SEEPAGE PITS ❑ Depth Size -2 =i -�==" Number iw SUMPS Distance to nearest: Well s�� Foundation L_ Property tine �� DISPOSAL,PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, st t 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."Contractors hiring or sub-contracting signature certifies the,following:"I certify that in the performance-of_the-work.for uvWch-this permit is-issued,I shall employ persons subject to workman's compensa- tion laws of California." �. p The applicant mus al r a equir nspec6ons. Complete drawing on reverse side. . Signed f Title: - � �_ .._ Date: r -� FOR USE`ONLY —•�{j•- i Application Accepted by Dater Area #� ±_ t Pit or Grout Inspection by Dat -�� Final Inspection byV_ � / Date Additional Comments: ------•�-----� ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy MS-6385 ! r Applicant- Return-alt-copies-to:-Environmental-Health-Permit/Setvices-'1601-E-Hazelton Ave.;P:O-Box"2009,-Stk,CA 95201— -- t t FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ,! PERMIT'NO. + EH 13-24(REV.10!831 - EH 1426 666 I