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r � APPLICATION FOR PERMIT If SAN JOA_ QUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 �� /Y4� 9C� City ��'G��r� Lot Size PM ' i7i9.N 7 Ta Owner's Name Address Phone Contractor A'-, tKL!:/tr/tr t Address ' `� License N .J'V�9/,_.Phone TYPE`OF WELL/PUMP: ^NEW'WELLY❑' I+VELL`AEPLACEMENT ❑ DESTRUCTION ❑ r 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 i1 Public C) Other UI Delta- Depth of Grout Seal :�, Type of Grout I I air Won _.Approx. Depth l I Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction El Well Diameter Sealing Material Itop 50') ^--I Depth • Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.? REPAIR/ADDITION I I -DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence SII-. Commercial� Other available within 200 feet.) � f Number of living units: / Number of bedrooms Character of soil to a depth of 3 feet:I CA Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J LEACHING LINE ❑ No. & Length of lines Total length/size k1 FILTER BED Ll' Distance to nearest: Well Foundation Property Line 9-- SEEPAGE SEEPAGE PITS V Depth 1rz Size 3 `�/S��.f /�� ' Number SUMPS L1 Distance too nearest: Well /VtP Foundation d-kb a Property Line b 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 must call for all required inspections. Complete drawing onWreverse side. Signed X Title: Date: 6 -ft?^ g 17 FOR DEPARTMENT USE ONLY Application Accepted by 10% e 9 Date Area Pit o� by Grout Inspection by Date Final Inspection f ate Additional Comments: D ❑ 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 s FEE AMOUNT DUE AMOUNT REMITTEDCK INFp o CASH flE,CEIVED BY DATE ZITN0. ' . + EH 1324 IREY.r�x s1 7 � D O —2 /� � � f i E�tqp EH 14-2t1 L (/p ^�