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� O APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' . t A (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. 4 yr, D„„.� c t, r• l Job Address �� aJ C7-. -.C.�lC-�C� nVe PWcity C✓ C Size PM Owner's Name 7i Address �� S rri-C��C 1 d w—B Phone Contractor's Name f<4A- !X41 & IDT-A License No. �) � 'E � Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1l�c ff SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE-AF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --� ❑'Industrial's "I x fO Open,Bottom_"� �-) 'In Manteca. Dia:-oflWell'Excavation� ,/(�- Dia. of Well Casing 11 F E?Domestic/Private ®'travel Pack ❑ Tracy Type of Casing J,37P_ e Specifications �7 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal � Ty a of Grout C i ❑ IrrigationDepth� �Eastern Su ace Seal installed by Repair Work Done ❑ Type of Pump -' 2 H.P. State Work Done 'I Well Destruction ❑ Well Diameter 1 Sealing Material ftop'50'1—” W Depth Filler Material IBelow 50'1 i l TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is j 1available within 200 feet.l � ` Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms c Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ i ------F Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LlNo. & Length'of lines + Total length/size t!� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS ❑ Depth Size Number �s l SUMPS ❑ Distance to nearest: Well Foundation Property Line 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,•state laws, and rules and regulations of the San Joaquin Local Health District. 4 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 app' nt m call for all require pectlons omple cawing on re side. 4 Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Are O Pit or 0ou spection by o�.�5R>1AbhiAa -Date Cl"1Sl5 Final.lnspection by C a),� Date 2m:: � s - 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., FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY k V DATE PERMIT"NO. INFO CASH + EH 13-24(REV.10163E EH 14-26