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I ' APPLICATION FOR PERMIT / '' 11 SAN JOAQUIN LOCAL HEALTH DISTRICT I 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. za- f Job AddressCity Lot Size�� PM_ Owner's Name _ Address . „�Contractor j�, ss ! ) . ��. icense No. F" hone 7' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J a i 1 PUMP INSTALLATION ❑ SYSTEM REPAIR �J OTHER ❑,t`'� l , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE i _FOUNDATION AGRICULTURE WELL OTHER WELL PATS. %SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation-- Dia. of Well Casing _ �r 1 ❑ Domestic/Private C Gravel Pack ❑ Tracy ' iType of Casin 9 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout-Seal—---- Type of Grout_' ' .. ❑ Irrigation _--Approx, Depth (- Eastern Surface Seal Installed by _�. '. \' Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter t Sealing Material (top 50'3 Depth __ Filler Material (Below Y F TYPE OF SEPTIC WORK: NEW INSTALLA ION L REPAIR/ADDITION DESTRUCTION C (No septic system petmitted if public sewer is IV v ' t available within 200 feet.) Install8tion will se_rve: Ree .dence 1i.__ Commercial'_�i_ Other _ E Number of living units:'L/siNumber of bedr ms Character of soil to a depth of 3 feet C-TANK ❑ Type/Mfg Ca Water table depth SEPTI \ - - pacity �No. Compartments_._ PKG. TREATMENT.-PLT:C Method of!2i I Distance to nearest: '" Well �. Foundation _ Property Line Ir -_ . LEACHING LINE No:& length of'lines _ r Total length/ . FILTER BED ❑ Distance to nearest: Well i 04 Foundation 4-211)_—Property-Line _ + SEEPAGE PITS - < Depth x 1p — -' 6sG A43mber if UMP Ll' .DistaAi a to nearest: Well bJ"r — Foundation Property Line '_0 D SL PONDS ❑ _ �.1 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 District. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must for all required spections. Co to drawing on side. Signed X `'�r Z&e "44 Title: / Date: FOR DEPARTMENT USE ONLY Application Accepted by /9 /L�) Date Area 7 Pit or Grout Inspection by Date Final.inspection by Date Additional Comments: S Li Stk 466.6781 ❑ Lodi 3&36521 ❑ Manteca 82307104 ❑ Tracy 8354385- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelfon Ave., P.O. Box 2009, Stk., OtFEE {' INFO AMOUNT DUE' AMOUNT!REMITTED CASH RECEIVED BY DATE fir PERMIT NO. + EH 7428 1REV.1 i n a, -70'na C rl Z-`1-- a(o g{p �Q