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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �/✓� >� /14.- L-ed 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'f 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. Job Address ti �Gd Cityiv�tot Si3e PM { f \\ �3�yS Owner's Nan,rz J Sd/IJ Ad dress Phone Z Contractor Address License No. Phone TYPE OF WELL/PNEW WELL '-7 WELL REPLACEMENT 7 DESTRUCTION U_- PUMP PUMP INSTALLATION L7 SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -_.- SEWER LINES DISPOSAL FLD. PROP- (.INE FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 7 Manteca Dia- of Well Excavation _ Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications f Fl Public 17 Other � C1 Delta Depth of Grout Seal --�: �� Type of Grout 1 1 Irrigation r _,.Approx�Depth� I I Eastern• Surface Seal Installed by Repair Work Done ❑ Type of Pump H-P. State Work Done _ `y Well Destruction LJ Well Diameter Sealing Material Itop 50') Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR DDITION DESTRUCTION I I (No 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 LJ Type/Mfg Capacity No. Compartments l- PKG. TREATMENT PLT. L It Method of Disposal Distance to nearest: Well Foundation Property Line �. r » LEACHING LINE _ No. & Length of lines __. Total length/sizelZ__. __ b FILTER BED ❑ Distance to nearest: Well Foundation Property Line-_ SEEPAGE PITS I I Depth r _Size _ __- .�_ Number SUMPS I I Distance to nearest: Well Foundation pY` 'P'prop'�e�y Line DISPOSAL PONDS L I I i 1 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 Di§trict, Home owner or licensed agent's signature certifies the following: "f 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 subcontracting signature certifies the following: "I c in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of CalifLunia" The appl' rt must call f uired i i s. omplete drawing on reverse side. / Signed w Title: - Date: FOR DEPARTMENYT USE ONLY T Application Accepted by _ Date Area Pit or Grout Inspection by I Date Final Inspection by f_/�ir-,P._ Date__7 1A �362i - Additional Comments: „—ti❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Ma t ca 823-7104 ❑ Tracy 835-6385 Applicant-Return all-copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 CIO rcaGJ, a.4 FEE INFO AMOO'U�NT DUE AMOUNT REMITTEO CASH / RECCEIIVED BY DATE PERMIT NO. + EH 13-24 IREV.i�r S� ` 6 �© �[� �y /-� `I EH 1426 1— S 4-