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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaq I tl Local Health District. +� City � Lot Size '- PM, Job Address ` KKKKJJJ �.� Phone Address / Owner'sName �} " Contractor Address icense No. � Phone NEW WELL El WELL REPLACEMENT C] ��ESTRU ION ED TYPE OF WELL/PUMP: SYSTEM REPAIR,f•3•� OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ OTHER WELL PITS/SUMPS } FOUNDATION AGRICULTURE WELL INTEND USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -• Dia. of Well Casing j ❑ In trial ❑ Open Bottom Ll Manteca g' pia.=,of.of Well Exr avationf` ` Specifications r � ` Casing omestic/Private ❑ Gravel Pack t.❑ Tracy%,�, -Type' - I`l Public 9'""��l=l"Oihei ""'T - f Approx. Depth I I Eastern Surface Seal Installed by I I Irrigation 1 j Type of Pum H.P. State Work Done Repair Work Done ❑ tp Well Destruction Sealing Material (top 50,I FI Well Diameter Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I) REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 'f available wijthin 200 feet.) Y i r Commercial— Other ' Installation will serve: Residence Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity /�Method of Disposal PKG. TREATMENT PLT- ❑ ) uj, ' i Distance to nearest: Well Foundation Property Line ? t Total�Jength/si ze LEACHING LINE' ❑ No. & Length of lines _� . 1 .rl- Foundation_ --�roperty-L-ine FILTER BED } L) Distance to nearest: Well _Size _ Number SEEPAGE PITS 11 Depth I _ Property Line SUMPS L� Distance to nearest: Well Foundation FhI DISPOSA bs- I hereby c rtify hat-1-have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and egula ons of the San aq'uin Lo 1 Health District. Home ow or or censed agent's _nature Mies the following: "I certify that in the performance of the work for which this permit is issued,f shall not employ an per n in such man as to b .o a subj i to workman's compensation laws of California." Contractor's hiring csub-contracting signature certifies the Ing: "I certify tin a rf rman f the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of C i ornia." The applic n c al r i i i s. pieta drawing on si _ i Title: Date: Signed X FOR ¢E RTMENT USE ONLY •- Application A'cepted by Date Area- D 2�W& Pit or Grout Irjspection by Date Final Inspection by Dat t Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523 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 �- CKRECEIVED BY DATE PERMIT'NO. < FEE AMOUNT DUE AMOUNT REMITTED CASH i t IINFO ..EH 13-24 IRfV.i a si 11 35 �9 alp EH 14.28