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APPLICATION FOR PERMIT L V ` SAN JOAQUIN LOCAL HEALTH DISTRICT l 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address 4ity '�' 'Di G -ct Lot Size M is Owner's Name Zt' 490 0 t'-L-b 1-iAddress J J t- Phone r 3 - Contractor's Namebft" �/� License No. Phone �! TYPE OF WELL/PUMP: NEW WELL� WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ n DISTANCE TO NEAREST: SEPTIC TANK -�•- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� S ❑ Industrial ❑ Open Bottom El.Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing ST iV Specifications ❑ Public fj Other ❑ DeltaDepth of Grout Seal a Type of Grout ❑ Irrigation .c-2-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump S H.P. �� State Work Done Well Destruction ❑ Well Diameter ,, Sealing Material Itop 50'-I,� r Depth �� 3 Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El-.(No septic system permitted if public sewer is / `f available within 200 feet.) Installation will serve: Residence_ Commercial_ Other v t Number of living units: I Number of bedrooms Character of soil to a depth°of 3 feet: r `` Water table depth SEPTIC TANK ❑I;Type/Mfg Capacity-:/ No. Compartments '"._ PKG. TREATMENT PLT. ❑ ;, ,.r. •' Method of Disposal" Distance to nearest: Well Foundation Property Line } LEACHING LINE ❑ �No. & Length of lines �^ Total length/size FILTER BED ❑ Distance to nearest: Well �- — Foundation Property Line ! F SEEPAGE PITS ❑ 'Depth' Size Number 01SUMPS, ❑ Distance to nearest: Well—",-Foundation r Property Line DISPOSAL PONDS ❑ hereby certify that I.have prepared-this application and that the work will be done'iri accordance with San Joaquin county ordinances, state laws, and ' rules and re lations`of,'the San Joaquin Local Health District. I home own r licensed agents signature certifies the following: "I certify that in,the pdrformance of the work for which this permit is issued, I shall not employ an p s8n in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies th fo wing:"I ify at in th rforma a of the work for which'this per'rnit is issued,I_shall employ persons subject to workman's compensa- tion laws o ornia." i 1 The applic st call fo I uir i ions. omplete drawin�on r e e sidy / Signed �` ,Title: #' -jjll Date: 3D ' o FOR DEP_ARTMENT USE ONLY Application Accepted by - `f'�' a Date �+ �� Area _5 A Pit or Grout Inspection by Date `� Fi1na}}I,Inspefation by Date ��"`' Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 -' k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CA 41 PERMIT 'NO.' BY DATE PERMI 'NO. +SEH 13-24(REV.10/83) I EH 1428'