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IF 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District JobAddress S( ,57) %} - City S� � Lot Size PM Owner's Name ' Address , 1� Phone Ih m Contractory --y � �..LLOg:�9 ss icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O 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 r FI Public 71 Other n Delta Depth of Grout Seal V Type of Grout 1 I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by _ O Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth. Filler Material (Below 501 O TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I UCTION I I (No septic system permitted if public sewer is � available within 200 feet.l G Installation will serve: Residence t�Commercial_, Other D _Number of.living units: Number of bedrooms z Character of soil to a depth of 3 feet: Water table depth VA SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L9--Iqo—& Length of lines Total length)size ��-yp--- FILTER BED ❑ Distance to nearest: Well-0_ Foundation� Property Line�Z) SEEPAGE PITS 11,4�—DepthSize 419 Number _ SUMPS ❑ Distance to nearest: Well Foundation 24qProperty Line �Q DISPOSAL PONDS ❑ 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 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 erson in suc an as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the wing:"I a 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 Cali ia.' T a plicant ust c for all re yylred t to dr on reeve pe side. S' d .l,❑ e9 1.�7Q� Data: �. FOR DEPARTMENT USE ONLY Application Accepted by �� Date ' ' 7 Area Pit or Grout InspectidDate Final Inspection by Date Additional Comments: tl'a4,L1'Lu024 t'B'i.Xv�=> ��af-� ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK - RECEIVED BY DATE PERMIYNO. CASH yam.-, ms EH 1121 tM lrx sl -70- 0c, �� l��—o , ��7 39-1 � EH 1426