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APPLICATION FOR PERMIT \./ SAN JOAQUIN LOCAL HEALTH DISTRICT n T 1601 E. HAZELTON AVE., STOCKTON, CA 7�.vw r �'Pa Telephone (209) 466-6781 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. ��//I ,., P Job Address If • •ta-N `Y+ei- — _e City ` Lh00 Lot Size PM Owner's Name c G Address yS'a f/w- Phone Contractor C Address!7t )/// ✓�C A License No.�� T a S�ls�hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR br OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FUD. 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 OlDomestic%Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications ❑ Public fl Other ❑ Delta Depth of Grout Seal Type of Grout 1 I Irrigation Approx. Depth 1 I Eastern SuH� a Seal Installed by - Repair Work Done 'X Type of Pump Scjj= H.P. 1 JL State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal (�Q 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 I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 1 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 Q rules and regulations of the San Joaquin Local Health District. 7 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." /J The appy mus all for all required 'R (Section, Compl drawing on reverse side.side. �I Signed «� Title: r(�f f.� Date: /1FOR DEPARTMENT USE ONLY ,'}� yl�� Application Accepted by `�/ /7—/` C�'✓r� Date �� U O Area Cy Date Final Inspection b x Date Pit or Grout Inspection by Y Additional Comments: ❑ Stk 466-6761 ❑ 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 [FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED By DATE PERMIT'NO.FO CASH EH 1124(REV.1/"5) -3S �� R.._, -� , e-lb,s EH N-2a