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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �ypl�aa-vow,v lt2 E�i ON AVE.,-STOCKTON, CA -r _ 1601 E. HAZ '� , � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 4 r -.iCofnplete in Triplicate) iApplication 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 i 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 JoagIuin r Local Health District.'" fi ;. {� /�., �, 5 3 f, .•,,f'1314V ai ff� '�� y � . c. ri Job AddressO 'City 3 Lot Size IC PM - Owner's Name x' Address //�>/� ( -Plio e� ' Contractor.- Address License No. Phone ? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �x FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ODomestic/Private LlGravel Pack 171Tracy Type of Casing Specifications i k ❑. Public " e ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern ' Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 11Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP R/ADDITON ❑ DESTRUCTION (No septic system permitted if public sewer is , available within 200 feet.) tInstallation will serve: Residence Commercial Oth Number of living units: Number of bedrooms I n ' Character of soil to a depth of 3 feWater table depth et. 1 I SEPTIC TANK El Type/Mfg Method of Disposal Capacity � No. Compartments �i l PKG. TREATMENT PLT. ❑ �I Distance to nearest: Well Foundation Property Line ' ;I a j i LEACHING LINE O No. &Vength of lines ! Total length/size Ij r FILTER BED ❑ Distance to nearest: Weil Foundation Property Line ' SEEPAGE PITS 0 Depth�l Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑ r 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 s rules and regulations of the San Joaquin Local Health District. if 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 Calif ia." I# The applicant t call f r all r i d inspections. Complete drawing on reverse side. p''y Signed , Title:, Date:-A�a"il CY Q+ / it FO EPARTMENT USE ONLY i!!' ' Application Accepted by ., Date �1� "`� Area_'l`°C" + Pit or Grout Inspection by Date Final Inspection by Date s Additional Comments: ❑ Stk 466-6781 E Lodi 369-362 ❑ Manteca 823-7104 ❑Tracy 836-6385 /Lce 40 �- /Jmn.� Applicant,- Return all copies to: Env'ronme t ealth Permit/Services 1601 E. Ha elton Ave., P.O. Box 2009, Stk., CA 9Q0J 4 FEE AMOUNT DUE AtkUNT REMITTED RECEIVED Y DATE PE iT NO. INFO + EH 13-24 (REV. ti/h sY - .. �,'ZS �� EH 1126