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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 !V56 Wk-?-SY I /V 6x9)A) City J t(e&l Lot Size PM Owner's Name A. —/ JI-e ✓-tffAddress s f,z M C n Phone ~ t� Contractor L Lie 1°Cu Address 4.12-6 S&I I r a License No. a Phone –2 l 6 F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171- _ DESTRUCTIOF PUMP INSTALLATION El SYSTEM REPAIR'❑`--OTHER�J DISTANCE TO NEARE TIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS © Industrial El Open Bottom ❑ Manteca ia. of We11 Excavation Dia. of Well Casing ❑ Domestic/Private 171 Gravel Pack ❑ Tracy Type o Specifications ❑ Public [I Other ❑ Delta Depth of Grout Se Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by"` (y Repair Work Done ❑ Type of Pump H.P. 1 State Work Done G Well Destruction C1 Well Diameter Sealing Material (top 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION V(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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Property Line _ %, "pi a <x A .1,-. i LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 District. Home owner or licensed agent's signature certifies the following: "t 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 st call for all rtgu4fd inspections. Complete drawing on reverse side. Signed Title: Date: FOR USE ONLY Application Accepted by Date r r?i Area Pit or Grout Inspection by ZZ Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. [� /J Q + ER 13-241REV.t/B57 �J _• �C, k43_"_S �/ ` { rs- �~� -1EFI 1428 /