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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �p 1601 E. HAZELTON AVE., STOCKTON, CA No wLI �, "Telephone (209) 466-67$1 � �� 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 ( { , cR 1 City - �f�f Lot Size PM i a Owner's Na 6- t + Address 1 /7& + 54,phone 1 eA Contractor Address License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ —PUMP INSTALLATION ❑ •SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO,NEAREST: SEPTIC TA SEWER LINES DISPOSAL FL-D.--1-2 PROP. LINE FOUNDATION ]CULTURE WELL OTHER PITS/SUMPS _ INTENDED'USE TYPE OF WELL PROBLEM AREA ONSTRUCTIO CIFICATJONS .r ❑ Industrial ❑ Open Bottom e.❑ Manteca Dia. xcavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel-Pack P tp ©Tracy of Ca Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eas Surface Seal Installed ! Repair Work Done ❑ Type of Pump H.P. State Work Done_ ^Q r J Well Destruction ❑—'Well Diameter" ` "Sealing Material (top 501) Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence --'Commercial_ Other "S Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [R-'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." Th cant m t call for all requir inspections. Complete drawing on reverse side. Signed X Title: ' F Date: FOR PARTMENT USE ONLY Application Accepted by &a, Ah, Date 3'' Area Pit or Grout Inspection by Date Final Inspection by Date : Additional Comments: 2 .�FL 4. N -�f 16C4_/� Lj� /may D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca •7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200�9Stk.�CA 95201(1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. '+ EH 1324{REV.t i N 51pp y� �� F EH 11-28 ��JJ C7�