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APPLICATION FOR PERMIT `' SAN JOAQUIN LOCAL HEALTH DISTRICT � �. IJ ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) HEALTH ENVIRUN E.NTAL.' c Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein�ddschbed�T : appI'C3tion 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 9/ O Z I C� , City Lot Size ' PM Owner's Name J Address v_z ��n�� `� " Phone �7v Contractor- -e��"" !'^~" Address License No/6 7� PhoneT�(r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLATION 6.4 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 IIk Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-----.--- -Easter-r.--Surface-Seal rout—_ _- roxrDepth -�O-Easterry - ----Sur:ace-Seat Installed by`'--�' `-- ❑ Irrigation -- "app t'J Repair Work Done a'Type of Pump H.P. State Work Done Well Destruction L7 Well Diameter Sealing Material(top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C.] REPAIR/ADDITION ElDESTRUCTION 11 (No ava septic system permitted it 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: T' 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. & Length of lines Total length/size FILTER BED -Distance to nearest: Well _— Foundation Property Line � 11 SEEPAGE PITS ❑ Depth 1 �� Size — Number SUMPS ❑ Distance 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 call for all req u d Inspecti 71complete drawing on reverse side. Date: - _ (Lr%jY Signed X Title: - lti FOR DEPARTMENT USE ONLY Application Accepted by �n� — Date — Area ev Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: CI Stk 466-6761 O Lodi 369-3621 El Manteca 823-7104 l.7 Tracy 835 fi385 Applicant- Return all copies to: Environmental Health Permit/Services-160.1-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK* RECEIVED BY DATE PERMIT N0. t F FEE INFO AMOUNT DUE "UN REMITTED CASH ��[j I SEH 13-24 iREV.t/9516 � ' EM 1426