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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. / Job Address 4 -,- )/� • `•,C�,S4� 10-e Y`c� /City: N Lot Size 1l)044XA PM Owner's Name Address _I S-7yv ��- I tn4j Phone Contract y dkddress 417Z& cense No Phone I. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION r SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK 4df O SEWER LINES DISPOSAL FLlf D. O PROP. LINE-4910 ` FOUNDATION 3,0— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATI /I ❑ Indyetrral n Bottom ❑ Manteca Da. of Well Excavation • Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 2 71 Public ❑ Other n Delta Depth of Grout Seal TT I -r I I Irrigation —Approx. Depth I 13ostern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 3 State Work Done >. Well Destruction ❑ Well Diameter Sealing Material (top 501 V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �{ Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/sue FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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: "1 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."Contractoes hiring or sub-contracting signature cenif es 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 jmussoc II for all requ Inspections. Complete drawing on reverse side. Signed X_ Title:�t-!;/'*2-�.— s'--r^~�'�� Date: `.0 G a FOR DEPARTMENT USE ONLY ^_ '._ Application Accepted by � Date1d Are C' Pit or rout nspection b Date 3 Final Inspection byl DatsJ-�L/ ditional Comments: ' AdEl 466-6781 Lodi 369-3621 ElManteca 823-7109 ❑ 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 CA BY D H RECEIVED ATE PERMIT NO. r ER13NIREINFO V.II —/ J`'s/ > 3? Call L�Llid � ' 3Y5 EN 1C -->s , - S