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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r a 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 Z7+2� �~ !' City — Lot Size 's PM- { Owner's Name ) Address Phone f�` k,,V I Contractor's Name /�!t License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATIONgOE SYSTEM REPAIR:. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ..DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLS OTHER WELL c PITS/SUMPS y INTENDED USE — Y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing JK Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout ❑ Irrigation ---Approx. Depths �❑ Eastern Surface Seal Installed by �, f Repair Work Done ❑ Type of Pump _..-- H.P. State Work Done 9 Well Destruction O Well Diameter ig .— Sealing Material Itop 501 N Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 -•' No,- TANK ❑ Type/Mfg Capacity � I ' No. Compartments PWG. TREATMENT PLT. ❑ j Method of,Disposal Distance to nearest: Well Foundation " Property Line LEACHING LINE ❑ No. & Length of lines '" Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ` I Number SUMPS 1-1Distanceto nearest: Well Foundation I 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, an rules and regulations of the San Joaquin Local Health District. �,`- I 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: rtify 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 Californ1 !" l 57 The applicantmu fo all re ,ions. C4lplete drawing on reverse side. w � ! Signed Title: -- Date: _ FOR DEPARTMENT USE ONLY ze 16A, Application Accepted by !Date Area Pit or Grout Inspection b I't to Final Inspection by Y� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi wY❑ Meh 623-7104 ❑ Tracy 83546365 s +, Applicant- Return all copies to: E ~' tal Healtermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT"NO. INFO CASH / 1 +EH13-24IRFV.101831 �+� `, �� /�•-�I $�"��} , EH 14-26 r '.