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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 Address City Lot siie Yzs..:a PM Owner's Name eAEO 2e Ce Address � /�/� Phone -' d Contractor's Name License No. Phone 61A�. %'�d TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR-❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W LELE L_ '--"STHER WELL PITS/SUMPS _ 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. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter s Sealing Material (top 50') (� Depth Filler Material (Below ') w TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 4 �J� available within 200 feet.) Installation will serve: Residence= Commercial_ Other _ Number of living units: /I Number of bedrooms Character of soil to a depth of 3 feet: C C- - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length-of lines d Toga( length/size O FILTER BED ❑ Distance to nearest: Well Uzr~rfii a Foundation Ze, Property'Line SEEPAGE PITS L1" Depth Z Size,__. Number_ SUMPS ❑ Distance to nearest: Well u�sG Foundation_,fD --Property Lirie 1 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. 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 applicaA�scall orall required inspections. Co. plate drawing on reverse Sid r Signed 07 2772 Title: C Date• FOR DEPARTMENT USE ONLY Application Accepted by Date t Area 19 AbiQ rr& j Pit or Grout Inspection byate 21 Final Inspection by C f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1--ID-Menteca--823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201FEE 1 I; INFO AMOUNT DUE AMOUNT REMITTED GK#CASH �... RECEIVED BY DATE PERMIT"N0. EH 13-24(REV.10/831 - .` ',� y 1 1 �' �"'f Ity EH 1428 �. [�C? -