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�.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRT NT)1601 E. HAZELTON AVE., STOCKTON, CA W barryr✓�. Telephone (209) 466-6781 QQ ��r go, i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��F1cVvd " (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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � c d a W r aJ�-4/A ` .Lot Size IA ' UPM �- Job Address JS f A tJ City Cra n.Qs 9-. /Aec1, w. p �a yN r H-n 4 Address Phone Owner's Name _„T fes' Contractor Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q ❑ Industrial (5Open Bottom C1 Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r. I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 1 I DESTRUCTION availabletwthine200 feet.) if public sewer is 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 .� PK9. 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 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant musl call for all required inspections. Complete drawing on re eeyy()bee side. p^7 X f L�`-cC�Y1�� Date: _� L X Signed X ��* Title: - - — -2 _ � / FO PARTMENT USE ONLY O Application Accepted by � C ,flWl/ Date "8 Area �t Pit or Grout Inspection by Date Final Inspection by Date Z� r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO . E 1}241REV.r/x51 3s,o s � r �a- 7�� r ER 14-M