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z l APPLICATION FOR PERMIT et SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Na k-o , ' Telephone (209) 466-6781 1 +, i 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. '"� p J �L� J �/' City T 'ry ' f I Job Address .�t�L3�t� L�Lu.Lot Size.'-3� — PM _r Owner's Name y Address 'S ! _/J Phone I Contractor Address License No. Phone ; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES _ DISPOSAL FLO. PROP. LINE. ' FOUNDATION ( AGRICULTURE WELL OTHER WELL PITS/SUMPS a t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ f ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack " ❑ Tracy Type of Casing Specifications M Public Cl Other Cl Delta Depth of Grout Seal i Type of Grout _ I I Irrigation —.-Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump I H.P._ « State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth" Filler Materiel (Below 501 Q f TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION 1 1 DESTRUCTION (No septic system permitted if public sewer is [®' Ii available within 200 feet.) A I Installation will serve: Residence Commercial Other 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: � Water table depth `t—', SEPTIC TANK ❑ Type/Mfg Capacity , No. Compartments PKG. TREATMENT PLTi O "� _ y Method of Disposal Distance to-nearest: Well_ , _ Foundation Property.Line a -_ r LEACHING LINE ❑ No. & Length of lines �' Total length/size FILTER BED ❑ Distance to;nearest: Well -Foundation `" Property Line SEEPAGE PITS I I Depth Size _ Number i SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ,1 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 l rules and regulations of the San Joaquin Local Health Diltrict. _ Home owner or licensed agent's signature certifies the following: "1 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." fThe applicant must caji for all required inspections. Comp) a drawing on reverse side. P e c� +� Signed X Title: Date: ` —6- O 1 t'ARTMENT USE ONLY ^Q, Application Accepted by Sn,�e, s e '�. Date-3-6 V Area t I Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE" AMOUNT REMITTED CASH CK RECEIVED BY ` DATE PERMIT'NO. i. EH 14-28 EH 13-24(REV.i i H 5) Q l! - ; 7 s°�