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APPLICATION FOR PERMIT` SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 7 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 wall/pump and the Rules and Regulations of the San Joaquin 1 Local Health District. ' !/ f �� r of Size PM Job Address v�� &4—Address 460 W Gly "/ Phone Owner's Name _ __.., _ -,. t.. �O F "' License No.�-W'hone �Q�2*7 F Contractor Address ' TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f ; PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE li FOUNDATION_ _AGRICULTURE WELL OTHER WELL PITS/SUMPS,, , INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t I Dia. of Well Casing El Industrial El Open Bottom .❑ Manteca Dia. of Well Excavation . , 1 %--L;Tracy "J Type of Casing Specifications ¢ 1 ❑ Domestic/Private ❑ Gravel Pack " Type of Grout t Ll Public ❑ Other V` , ,',► 0 Delta Depth of Grout Seal by ❑ Irrigation Depth ❑ Eastern """"°SurFace`Seat`Installed 1�. Repair Work Done El Type of Pump H P. ,3. r State Work Done i Well.Destruction ❑ Well Diameter. Sealing Material {top 50'1',''' _ ' ""-- hw�.'�-�-`.,."'""'._"` :"'_'�`fille�Material (Below�0`i-`..T.,...,.r.�,� TYPE DF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTR�TION ❑ available e1w'tlime200 permitted if public sewer is f ' Installation will serve: Residence— Commercial✓ Other . Ae Number of living units: Number of bedrooms Y .,- i=ice�� Water table depth T .t Character of soil to a depth of 3 feet: + SEPTIC TANK ❑ Type/Mfg Capacity j No. Compartments f ' Method of Dispo41 PKG. TREATMENT PLT. ❑ 1 1 i Distance to nearest: Weil Foundation Property Line r s xj € / �-. Total length/size LEACHING LINE C1 No. & Length of lines ` _ s # FILTER BED [I Distance to nearest: Well Foun�d�atiioo Property Lina / a _Si J , ' ilVumber SEEPAGE PITS Depth '2�,_ 5UN1R ❑ Distance to nearest, Well Foundation—� Property Line .+ ©ISPO�AL PONDS ❑ ,. -- ---_ - _—.� 1? - �state laws, and I hereby certify that I have prepar d this application and tha he work will be done in accordance with San Joaquin county ordinances, rules and regulations of the San Joaquin Local Health District. a 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 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 laws of California." i { The applicant must for all 'red inspections. Complete drawing on reverse side. le — -� Date: — < Signed FOR DEP RTMENT USE ONLY ; Date r Area Z App• ation Accepted by� r % Date ..Prior Gr u Inspection by y�Dat '+ Final inspection by t � ` ol Additional Comments:! r ,Y p Stk 466 6781 ❑ Lodi 369 3621 © Monte 823-7104 ❑ Tracy $36385 � � 95 0 � '.. Applicant- Return all copies to: Environmental Health PerrrmitlServil ese 601 E. Haze on Ave., P.O t6 x2009, Stk., C 4*7 rkO O i e 40. ia- yf� i FEE CK RECEIVED BY DATE PERMIT"NO. y INFO AMOUNT DUE AMOUNT REMITTED CASH AAS►/f i,� '+EH13.241REV.1/651 - - • ,��s/"�� O EH W26 ! V