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Nvt APPLICATION FOR PERMIT ® .O a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1,YEAR FROM DATE ISSUED j (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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Z;Jhx Job Address ✓ L1 n Q � City �* Lot Size PM — i E i ie h Kr4 h"CtAddress ✓r•a Phone �p Owner's Name y 4 I J jl ar 1�Lrt . License No. � Phone 3 3' �a�2 Contractor's Name ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK `.��-7 SEWER LINES_ DISPOSAL FLD. PROP.- LINE FOUNDATION�...— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO � A Ilia, of Well Excavation_ Dia. of Well Casing' ❑ industrial -Open Bottom ».�.�;�❑:Manteca � ---f �omestic/Private ❑IGravel Pack ❑:Tracy Type of Casing � {*�� - Specifications �L�L '� 11 Public ❑ Other moi] Delta (. , Depth of Grout Seal �L� Type of Grout Px 4" 124 ❑ Irrigation _4pprox. Depth 0 Eastern Surface Seal Installed by Repair Work Done _+ Type of Pump State Work.Done f Wel! Destruction Well Dia Se�aiing-Material (top 501 Depth Filler Material (Below 501 r t B TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑.(No septic system permitted if public sewer is f_ available within 200 feet.) ll nn Installation,will serve: Residence_ Commercial_ Other V 1 Number of living units: Number of bedrooms',— Character edrooms Character of soil to a depth of 3 feet: "" Water table depth `►'I I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I` PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well "' Foundation ^_-Property Line LEACHING LINE ❑ -No. & Length of lines R -' t Total length/size S FILTER BED ❑ Distance io nearest^" '-Well_=:!�_ --�Foundatio r- 'w yProperty Line SEEPAGE PITS ❑ Depth Size ¢ 1 '' Numtiar SUMPS ❑ ;Distance to nearest: Well Foundation Property Line- ` —"" DISPOSAL PONDS ❑ hereby certify that I 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-- —'F i Home owner or licensed agent's signature certifies the following:�T certify that,i iLthe,performance of the work for which this permit is issued, I shall not ,I employ any person in such manner as to become subject to workman'§compdnsation lawsraf California:" Contractor s hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for wliich this•permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." �� f F The applicant u call for emir pe Complete drawing on reverse side 1 w ITitle: Date' i Signed f� FOR DEPARTMENT USE ONLY !/� l Application Accepted by date Area t. Pit or Grout Inspection by Da Final Inspection by Date r ' Additional Comments: ❑ Stk 4664781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 N Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j FEE I AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIVNO. INFO t _+EM 73-24(REV.10183) Eli 1424