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A*kAPPLICATION FOR PERMIT G SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED l (Complete 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. " Joo 0 3 9a� o ' b ddress?�� l-b�1' -_- City /�� Lot Size PM y Owner's Na-35",;L_ Address phone i Contfactor ` ` Address License No, Phone_ TYPE OF WELL/P MP: ._ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEST.-SFU4, TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION�CiR CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR CON TR#GTJ.Q SPECIFICATIONS ❑ Industrial ❑ Open Bo ❑ Manteca Dia. of Wali Excavation Dof Well Casing ❑Domestic/Private vel Pack, ❑ Tracy Type of Casing Spia.ecifications �V f`l Public ❑ Other 171 Delta Depth of Grout Seal Type of-Grout I I Irriga ' _.-Approx. Depth I I Eastern Surface Seal Installed,by air Work Done . U Type of Pump- H.P. t � ' State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 51 Depth Filler Material {Below 50'), TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION L I DESTRUCTION &Wo septic system permitted if public sewer is 4 , d 'available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK a ❑ Te/Mf YP 9 t PKG. TREATMENT PLT. LJ Capacity No. Compartments_ - - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well FoundationProperty Line l-{ ` SEEPAGE PITS _ I ) Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑' S 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 1 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 empioy any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature i 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 applicant must c 11 for all requir inspections. Complete drawing on reverse side. Signed Title: Date:. FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by_ -1J� Data J idditionai Comments: b.W 0 Stk 466-6781 ❑ Lodi 369-3621 11Manteca 823.7104 ElTracy 835-6385 ' pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO SR RECEIVED BY DATE PERMIT NO. h + EH 13-21(REV. /ns) EH 1948 �7 �J i ♦`/ , � lI