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%m,/ APPLICATION FOR PERMIT *ft/ SAN JOAQUIN LOCAL REALTR:DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r. 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 Ryles and Regulations of the San Joaquin Local Health District. r Job Address City Lot Size PM t Owners Name Address 41 {� _ Phone ` r •6i 7 / Contractor Address License N '>"Phone _996 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L 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^ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout W ❑ Irrigation r• --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done r'❑ �Type of Pump r! H.P. State Work Done Well Destruction ❑ -NEall Diameter ._. Sealing Material (top 50') Fill r Material (Beloyv 501 - available within.TYPE OF SEPTIC WORK: NEW INSTALLgTION REPA R/ADDITION DESTRUCTION ❑ (No septic permitted if public se �.Is t t 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 i SEPTIC TANK >__—Type/Mfg�� V Capacity No. Compartments r PKG. TREATMENT PLT.❑ y r - Method of Disposal Distance to nearest: Well 'r Foundation r _ _ � � Property Line LEACHING LINE X No. & Length of lines � iI - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �� T Property Line SEEPAGE PITS - ❑ Depth 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: "1 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 requir ' specti g. Complete drawing on revue. Signed Title: Date: ? FOR DEPARTMENT USE ONLY Application Accepted by f h Date C3 Y3 Area CMZ Pit or Grout Inspection by Date I V Final Inspection by Dater r Additional Comments: _ 1,1191'"i 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 17 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r. y INFO EEE AMOUNT DUE AMOUNT REMITTED' ".l ASHD RECEIVED BY DATE PERMIT'NO. EEH 1�24 H tb]91REv.Ves)