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a APPLICATION FO,R PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address City Lot Size Owner's Name.AW,60(e� R. �.f11 tr2 Address �U /I &Wawgo Phono Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications Fl Public 171 Other � Cl Delta Depth of Grout Seal Type of Grout _- I Irrigation _..Approxtepth I I Eastern Surface Seale Installed by i Repair Work pone ❑ Type of Pump H,P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')' k Depth �I –� - Filler Material (Below 50') _ ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence)J Commercial— Other Number of living units: I Number of b Brooms Character of soil to a depth of 3 feet:/ '_ _ Water table depth SEPTIC TANK L)( Type/Mfg _L Capacity 0 Ga i, No. Compartments j PKG. TREATMENT PLT. ❑ i / &SQ Method of Disposal`y Property Line Distance to nearest: Well o Foundation I LEACHING LINE jX No. & Length of lines -C Total length/size FILTER BED ❑ Distance to nearest: Well Foundation &9T Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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, and 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 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 cerci at in the pert rmance0 of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws ofifo ia." K The appri ant mus or II r uire ens ctions Complete drawing on arse side. Signe Title: Date:rl FOR DEPARTMENT USE ON i Application Accepted by Data Area Pit or Grout Inspection by }� Date Frnnaa=Inspec ion by Date Additional Comments: � /f; ❑ Stk 466-6781 ❑ Lodi 369-3621 = -❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environr}nental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 ' EE INFO AMOUNT DUE � AMOUNT REMITTED CK CASH/ RECEIVED BY HATE PERMIT'NO. + EH EH 14-26(REV,t/8 51 .I1r