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APPLICATION FOR PERMIT /l ` SAN JOAQUIN LOCAL HEALTH DISTRICT f rr 1601 E. HAZE i ON AVE., STOCKTON, CA r L 2 - „ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in Triplicate) ..tion 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 .uein 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 ,ocal Health District_. Job Address City 40 r4 Lot Size G?U[`5' PM Owner's Name I r � cl Ad ress C Phone Contractor Address o wl fo VIIJ License No.�07 7 el Pho 07 7',f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER $' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 7!D AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION O �[Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of CasingSpecifications , ("1 Public ❑ Other n Delta Depth of Grout Seal 1:760 Type of Grout /►t I I Irrigation 3QA20__Azpprox. Depth I l Eastern Surface Seal Installed Repair Work Done U Type of Pump H.P. State`Work Done _ M� 'VGell Deseuction ❑ Well Diameter _ Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted-if public sewer is available within 200 feet.} Installation will serve: Residence, Commercial_ Other Number of living units: Number of bedrooms ' 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 Line �r LEACHING,LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS ( I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 Dibtrict. 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." The applicant must call for all required inspections. Comp a drawing an reverse s" Signed X 't_ Date: 9,J16/C? FOR DEPARTMENT USE ONLY Application Accepted by _ A _ Date G OArea PitGro Inspection by Date / d Final Inspection by -�` /r DateA� /�� Additional Comments: �S�r .k r r fjy �;�� Q/�( �'� (9ft ft ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 �— r� prvtr'kt f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201FEE I INFO ,fAMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERM17-NO. a EH14,211REV.renal 7Y /�r