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R APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 (FJ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r 1 (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. V� Job Address _ `�� City. Lot Size PM Owner's Name 1 _ Address _r j(_0 Phone Contractor �Ci*�'� Address lcx_� -C.t►-)t _License No: Z ! Phone_ TYPE`OF WELL-%PUMP: r ,� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC LTURE W L OTHER WELL PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CO STRUCTION SPECIFICATIONS s ❑ Industrial ❑ Oen Bottom ,E1 Manteca ,a..of Well Excavation --- ' . P Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications ❑ Public ❑ Other ❑ Delta D th of Grout Sea! Type of Grout i ❑ Irrigation Approx. Depth !❑ Eastern Su ce Seal Installed by R Repair Work Done ❑ Type of Pump H.P. -State Work Done Well Destruction ❑ Wel! Diameter Sealing Material Itop 50') Depth Filler Materia! (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is r =-= vailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: I Water table depth C SEPTIC TANK �r ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ {. Method of Disposal 'Distance to nearest: Well Foundation_ Property Line1 , sr LEACHING LINE ~�,,❑ No. & Length of lines ti Total length/size t , FILTER BED LlDistance to nearest: Well <- Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 1r SUMPS ❑ IlDistance to nearest: Well Foundation Property tine " DISPOSAL PONDS. FI 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. 1 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' "I certify that in the performande bf the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Q r .i The applicant m s all for all req,wired inspections. Complete drawing on reverses side. Signed Title ✓ Date: 2z� J FOR DEPARTMENT USE ONLY r Application Accepted b i Date��2-1- l Area I i Pit or Grout Inspect?y y � • 'j Date Final Inspection by Qate Additional Comments: i1 �Y r►+ ✓� ',It g - .» ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 y_AMOUNT.REMITTED- K. RECEIVED BY. DATE PERMIT-IVO. r t EH13-24(REV. 2� � EH 14-28 - �-/� �.