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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 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. �UT n A('''"' Job Address _ �/� __ LX, City.7�'AG� Lot Size PM Owner's Name . ___9A0x6tiM/,0VG+ Address _._— Phone Cor.tracVr �� j W ff� � .Address e0 __ �� License No.OdP,d/sem Phone TYPE OF WELL/PUMP:-. NEW WELL C WELL REPLACEMENT O DESTRUCTION Ll \ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -. PROP. LINE OTHER WELL FOUNDATION ' AGRICULTURE WELL _ PITS/SUMPS INTENDEDlUSE ;YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O.Open Bottom ❑ Manteca Dia. of Well E4tcavation _ Dia. of Well Casing -- A IS Domestic/Private O Gravel Pack O Tracy Type of Casing --- Specifications Public ! I Other [ Delta Depth of Grout Seal -_ Type of Grout__,. : I)Irrigation —Approx. Depth l I Eastern Surface Seal Installed by---- Repair y --.Repair Work Done' ❑ Type of Pump H.P. _. State Work Done Well Destruction t O Well Diameter Seating Material flop 50') - Depth _ =--- Filler.Material (Below 50') •t• r _..____. _,.,.- - TYPE OF SEPTIC WORK: NEW INSTALLATION)?' REPAIR/ADDITION I I DESTRUCTION : I (No septic system permitted if puhlic sewer is r I available within 200 feet.) �J\ Installation will serve: -Residence l Commercial_ Other f n Number of living units: �— Number of bedrooms__f-_ + 1 "\ �Cf� 'a�ter of soil to a depth of 3 feet: "��/., `llr-- -Wafer 6le depth SEPTIC TANK ❑ Type/Mfg r Capacityl�[dC� No. Compartments PKG. TREATMENJ PLT. O q ��T �-�--- Method of Disposal IF--7 - a 1� Distance to nearest:. Well Foundation /10 — Property Line r LEACHING LINE No. & Length of lines �/"�/l/O Total length/size - 01 FILTER BED 1-1Distance to nearest: Well-/A2 Foundation Property Line _h SEEPAGE PITS I I Depth Siie' - .. Number SUMPS L7 Distance to nearest:, - Well Foundation Property Line . DISPOSAL PONDS O - I hereby certify that t 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 Dstrict. 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 compeff§ation laws of-California." Contrartoes 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." ` 3 The applica�r t must call for all re ired in ctions Complete drawing on reverse sida. Signed X' � � 1 Title: �J Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date �S Area Pit or Grout,Inspection by Date_ Final Inspection by _ Data_1Sy Additional Comments: - O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O Tracy 835.6385 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 x CA RECEIVED BY DATE PERMIT'NO. INFO S H . EN 13.24 IR , -�� Lt -zZ -a3sf� ' EH 14-2a