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S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT =' 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . i (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 compliancewith 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 d1 7 /'F' ° /' �� City �T6��f��Lot Size PM '/�i�/s'D,v /Y/ 6 e 0 IlTe y�A /y- Ii 1,er/9r_ _ Phone Owner's Name _ Address Contractor_ WA' � A�1' Address License No. Phone ` TYPE OF WELL/PUMP: $ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ o PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EJ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP E° FPUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS 1 j INTENDED USE_ (TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ONS I ❑ Industria! r� CY Open Bottom ❑ Manteca Dia. of W vation Dia. of Well Casing I 171 Domestic/ 0'Gravel Pack ❑•Tracy a of Casing Specifications — I FI Public l7 Other 41 Depth of Grout Seal Type of Grout I ! Irrigation _ DQ Ap pth I ) Eastern Surface Seat Installed by - ,I. Repair Work Done pe of Pump H.P. State Work Done 6 Wel n ❑ Well Diameter Sealing Material It 50'1 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is {` „„ available within 200 feet.) v �. •Installation will serve: Relidence Commercial— Other 71 Number-of living units: III _ Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth r� I SEPTIC TANK"'""`❑ TypelMfg Capacity No. Compartments l❑ � PKG. TREATMENT-PLT- �� Method of Disposal l F Distance to nearest: Well t foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line i, SEEPAGE PITS f,l Depth Size Number SUMPS ❑ . Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i t 1 hereby certify that I have plrepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k 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, l 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: "1 cer4ify 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." t The opl2licant must call for all required inspection Complete drawing on reverse side. ff l Gl t Signed X Title: Date: FOR DEPARTMENT USE ONLY .. Application Accepted by �E Date cf, l Area Pit or Grout Inspection by �! M Dat Final Inspection by Date Additional-Comments:5/ ,— / ,631 ❑ Stk 466=6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Re urn all copies to: Env�iroental salt P rmit/Services 1601 E. Hazelton Ave., P.� B�ox 2009, CA 9 01 J .(l. � Q f�- -C.�[� [er r Z. . " INFO 4mbUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT NO. �- ! + EH 1 -241REV. 51 cif �� ^ � EH 11-26 i -J i ��