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APPLICATION FOR PERMIT iiOV 1 ^pp l iJ0 SAN C LOCRL HEALTH DISTRICT E. HA l� 1601 E. HAZEL TON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 q '{ SAN JOAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE ISSUED HEALTH DISTRICT (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 Savo Jmow.. Subdivision Na e Owner's Nam " dAddress _S'oeo (r. /�,. Phone Contractor's Name 4p,Zr _,___.r License No. 1A 23 73 _ Phone ,r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION IQ SYSTEM REPAIR 0 OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ Q� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia, of Well Excavation 0 Domestic/Private 0 Gravel Pack 0 Tracy Dia. of Well Casing 0 Public [—j Other 0 Delta Type of Casing [j irrigation Approx. ❑Eastern Specifications 0 Cathodic Protection Depth Depth of Grout Seal 0 Geophysical Type of Grout 0 Other Surface Seal Installed by Repair Work Gone Z Type of Pump State Work Done 0yyy,; Well Destruction Lf Well Diameter Sealing Material (top 50') N Depth Filler Material (Below 50') li 0- TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 1=1 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c3 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE j-1 No. 6 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS t_1 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 workmanS 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 compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_(-4,# -M Pn.._r ,te Title: Date: r FOR D PARTMENT USE ONLY L� 0 Stk 466-fi781 Application Accepted by Area J Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date .& Manteca 823-7104 Final Inspection by _41 - •- Oc+oz.n Date � 0 Tracy 835-6385 �- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., LA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO R3 tea- IaB 10182 500 EH 13-24 REV. 10182 14-26