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Z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 forgell/pump and the Rules and Regulations of the San Joaquin Local Health District. Y060 /Job Address til f hl _t3l`_ City S f� of Size a 3 q �C m Owner's Name Address S Phone `"'"TContracto?s Name^""�=� "�N`�LT Ir� 1�L_LLicense No: - 5 I q Phone -'q q� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPQSAL FLD. PROP. LINE .-_FOUNDATION._. AGRICULTURE WELL __OTHER WELL —,PITS/ -SUMPS_; INTENDED USE ❑ Industrial ❑ Domestic/ Private ❑ Public j ❑ Irrigation Repair Work Done Well Destruction TYPF f1F WFI 1 LJ Open Bottom .ter'`- ❑ Gravel Pack ❑ Other . ---Approx. Depth :1 Type of Pump Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal ❑ Eastern Surface Seal Installed by H.P. State Work Done _ Sealing Material (top 50') Filler Material (Below 501 Dia. of Well Casing Specifications V Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is AMOUNT REMITTED s. RECEIVED BY available within 200 feet.) PERMIT'NO. Installation will serve: Residence _1_ -`Commercial = Other" ` ` "'" " 134-D� Number of living units: Number of bedrooms O Character of soil to a depth of 3 feet: 4 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal O Distance to nearest:. Well tla -FT-Foundation Property Line I LEACHING LINE o. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS ❑ Depth Size T Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS Cl 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." Contractors 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- of California." r The applic st call f all required ' spec ns. C _ plet@.drawing on r -verse side" r} Signe Title: _ - Z, Date: �" r FOR DEPARTMENT USE ONLY Application Accepted by _ a\ Lr) _ Date a Area Pit or Grout Inspection by Date Final Inspection b Date'!~ Additional Comments: - .-- ❑ Stk 466-6781 57 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13.24 iREV. 10/83 EH 14-28 FEE INFO AMOUNT DUE J AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. 134-D� -[- I� 2 -