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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (203) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sar,Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is j made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addressoz.77,f4z ,��,4�9�e ' - _ City 4 Lot Size PM Owner's Name I/-_e Address ..� 3!LLr... _. Phone Contraclor-u'1�� E �Address � ��L/t S�•°•t J41ye License No.f I Phone TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEMENT-0. DESTRUCTION ❑ ; l —� PUMP INSTALLATION D SYSTEM REPAIR ❑ + OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . _...._— FOUNDATION _. AGRICULTURE WELL OTHER WELL _ PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 171 Open Bottom G Manteca Dia. of Well Excavation _ Dia. of Well Casing 0 Domestic/Private O Gravel Pack G Tracy Type of Casing__._ Specifications ('I Public n Other n Delta Depth of Grout Seal Type of Grout.__.,_ i I Irrigation -_--Approx. Depth t 1 Eastern Surface Seal Installed by Repair Work Done u Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth _. Filler Material 18alow 50'1 _.— TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _ J Number of living units: Number of bedrooms AiW . , Character of soil to a depth of 3 feet: Water table depth _. SEPTIC TANK Type/Mfg Capacity No. Compartments _PKG...TREATMENT_PLT,❑ Method of Disposal .._._...... Distance to nearest: Well Foundation ...._ Property Lire .... �..__ LEACHING LINE No. & length of lines „_ Total length/size___ - FILTER BED - r I:::i Distance to nearest:_ Well ____...._ Foundation _.. Property Line_ SEEPAGE PITS I I Depth _—Size— Size_ __.....__. Number SUMPS ( , Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .0__ I hereby certify that I have prepared this application and that the work will be done an 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 pemrit is issued, I shag 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 shell employ parsons subject to workman's compensa- tion laws of California." _ �� ,... r - - - The applicant mujil call for all required ins s. Complete drawing onn rgversa side. ,h" Signed _ Title:__ ' Date: V FOO Afl7MENT USE ONLY , Application Accepted by — oat Y Area Pit or Grout Inspection by Data Final Inspection b yDatrf Additional Commants: 1 Li Stk 46667$1 0 Lodi 369.3631 Cl Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201FEE I 1NE0/ AMOUNT nDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. El114.2e fC �✓ �+ 4r