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y APPLICATION+FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA No WF-LL Telephone (209) 466-6781 f �j = PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 A .,(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 Rul Local Health District. es and Regulations of the San Joaquin ' Job Address C/ t37J[j f City PM Lot Size Owner's Name i - _� Address �ZU�? a U Phone Contractor Address License No. Phone { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �❑ r DESTRUCTION ❑ r PUMP INSTALLATION-C.- YSTEM REPAIR -p - " OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISP AL FLD- PROP. LINE FOUNDATION AGRICULTURE L HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CoNSTIR N SPECIFICATIONS ❑.Industrial ❑ Open Bottom ❑ Manteca ; • Dia..0 0111 cavation Dia. of Well Casing ❑ Domestic/Private 1:1 Gravel Pack-4 ❑ Tracy a of Casing ❑ Public ❑ Qiher ` _ Specifications "'❑ Delta Dep[h of Gout Seal F Type of Grout ❑ Irrigation _.tApprox. Depth ❑ Easter #� i A 'r ' ` s Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction C] Well'Diameter Sealing Material (top 50') Depth Filler Material {Below 501 # x TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic,system permitted if public sewer i available within 200 feet.l s installation will serve: Residence Commercial_ Other ¢i Number of living-units: t'Number of bedrooms Character of sail to a tlepth of 3 feet: I ? SEPTIC TANK ❑ Type/Mf g Water table depth g. Capacity No:.Com artments ' PKC. TREATMENT PLT. EDa f -V p Method of Disposal Distance to,nearest: " -Well Foundation Property Line f I } b !!! LEACHING LINE 'a ❑ No. & Length of lines ��,� ._ Total length/size FILTER BED iii . ..k . .- -� ❑ .Distahce"to nearest; Welf Foundation I � Property Line a SEEPAGE PITS ❑ Depth 1 *"" "=' f p Size # Number SUMPS ❑ Distance to nearest: Well - Foundation *4 , � r v r Property Line DISPOSAL PONDS ❑ I i I I herebycert{ that I,have re pp certify 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." ' Gd pp Ican must call f r all re fired inspections. Complete drawing on reverse side. �. Title: r Data: �FORDEPARTMENT USE ONLY A ► M pplication Accepted by Data Area Pit or Grout Inspection by '• Date Final Inspection by Date Additional Comments{' � 11 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca �B23 7104 q Tracy 835-6385 04/! { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEER,AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED 8Y DATEPERMIT NO.EH 13-24(REV.1'/R 5) .� EH 14-28 Y ' `.�� i �/ 1� �7 �'"I