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i + APPLICATION FOR PERMIT ?4 SAN JOAQUIN LOCAL HEALTH DISTRICT ?: 1601 E. HAZELTON 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 Ne 549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. 6' L1lt City Addrrss Loot Siizze� o?-•, — PM Owner's Name y—�� D o 14-A Address Phone Contractor's Name ,6{ License No. ; _— — Phone TYPE OF WELL/PUMP: NEW WELL iJ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.._— PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom C Manteca Dia.of"'oil Excavation Dia. of Well Casing Domestic/Private v Gravel Pack Tracy Type of Casing_ __ Specifications M Public G Other E: Delta Depth of Grout Seal __ Type of Gioi-t C Irrigation ---Approx. Depth C Eastern Surface Seal Installed by--- Repair y Repair Work Done Type of Pump _ H.P. _ State Work Done_ C� Well Destruction C Well Diameter Sealing Material(top 501 Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C: REPAIR;ADDITIONIx DESTRUCTION L (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-Afi Commercial_. Other Number of living units: Number of bedrooms .1_._ Fes. Character of soil to a depth of 3 feet: ;Z4_ A&L& `L' Water table depth SEPTIC TANK = Type/Mfg --- Capacity No.Compartments PKC. TREATMENT PLT.L: Method cf Disposal �J 6 Distance to nearf est: Well ____ Foundation Property Line LEACHING LINE C No. 8 Length of lines Total!engtfi/size FILTEP BED �( Distance to nearest: Wall� Y�.� Foundation- Property Line r SEEPAGE PITS 7 Depth _Size _ Number. + - Property Line SUMPS _. Distance to newest: Well___ Foundation__— DISPOSAL PONDS I hereby certify that 1 hati'a prepared this application and that the work vill be done in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Nome owner or licensed agent's sigrature certifies the foliuwing:"I certify that in the performance rn 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 I s of California." The app!icanr must call f all reqpsed inspections. Complete drawing on reverse side. -�E -- �� `lG Title:_—! ti_ — Date: r Sic-, •d X- -- t r FOR DEPARTMENT USE ONLY ? APpiiLstitn Accepted by �% t rI`fy) Date AreA Pit or Grout Inspection by —_ r� _ Data Findl Inspection by �' , ATS Date / Additional Comments: -- -- t Stk 456.6781 -- Lodi 369-3621 Manteca 823-7104 '5-638 C Tracy 835 Applicant- Return all copies to: Environmental eal• Permit'Services 1601 E. Hazeltor.Ave., P.O. Bov 2009, Stk., CA 45201 FEE AMOUNT DUE AMOUNT REMITTED CK= CFIVEG 8Y DATE PERMIT NO. INFO ___ CASH d Fh f3 24-REV •u s:rl !_1 17 r; 'j h►�. R