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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 ;rjg��Spplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and FtegufatildrSs of the San Joaquin Local Health District. Job Address R51 t`, CityJTF7�/.t�tf" Lot Size © PM Owner's Name W` in C n ( O .O y""t��ddress 45d 5 pJ �a`-r` Ism- � Phone Iq Contractor UJ" Address 74-97 E- k°Ve 14L-acense No. 36I!FY - Phone I>3 `41 30 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAI ❑ OTHER ❑ \ DISTANCE TO NEAREST: SEPTIC TANK _ e!!= SEWER.LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI< NS Zoj ❑ Industrial Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing y�1 ` O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �FC�- Specifications • O \�\ 1`l Public n Other ❑ Delta Depth of Grout Seal Type of Grout__ ➢(irrigation qv-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamete Sealing Material Itf50) Depth Filler Materi elow TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 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: We Foundation Property Line LEACHING LINE ❑ No. & Lengt�ne A�st: Total length/size FILTER BED ❑ Distance to Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Dist ce to nearest: Well Foundation Property Line 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 Fall for all required ins actions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Cor Application Accepted by �A p/ Date �,�te/-,JJ-��S�r - Area Pit or Grout Inspection by Date Final Inspection by, U J `ld4gf� Date�O Additional Comments: ❑ Stk f A66-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 pli�A�r Retu Ac pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0V FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �-y� EH 13-24 IREV.i i x 51 �_ EH 14-26 "CJ O V