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ry APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telepholie (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete its 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. ry ,y Job Address yFoO? �1�. it]fi�/ �1 �. ___ ___ City/� off Lot Size PM Owner's Name fL0� Address $4ME �tv Phone Contracts N Mess J- No. Phone_ 2;7— TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLOliCV PROP. LINE FOUNDATION �` AGRICULTURE WELL `— OTHER WELLYCF7:7,�_ f ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS r El Industrial LI Open Bottom Manteca Dia. of Well Excavation 11 Dia. of Well Casing Domestic/Private >ICGravel Pack ❑ Tracy Type of Casing eX7 lel 0!asf Specifications f'1 Public f 1 Other {1 Delta Depth of Grout Seal ype of Grout I I Irrigation /�I_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is O available within 200 feet.) �7 Installation will serve: Residence_ Commercial_ Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity tul No. Compartments 1 PKG. TREATMENT PLT. ❑ 'M CA�ry Method of Disposal Distance to nearest: Well IMIFour�aiti7on7 ``� Property Line LEACHING LINE ❑ No. & Length of lines nen. IT IVIENIAL f ere,.r.HEA otal length/size FILTER BED ❑ Distance to nearest: Well f=oundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll 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 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 st II r all re fired inspections. Complete drawing on reyorse side. Signed X Title: .v1-t /!/ _ Date: O DEPARTMENT USE ONLY r Application Accepted by Date � �! � ' ,� Area �G Pit or Grout Inspection by Date -l! Final Inspection by Date Additional Comments: , d' ❑ Sik 466-6781 ❑ Lodi 369-3621 LI Mant ca a23-7104 ❑ Tracy 839-&-t85 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED CCK 9 RECEIVED BY DATE FERMIT'NO. +.EH 13-241REV.1i145) EH 14-26 ^5