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�ua APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 I 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 AddressT ' 1/ ^^+— City 'is /\ Lot Size IS-O pM Owner's Name z Address Phone ` Cont�act6F Tn a _CAD-, S�ddre5s '~= - {cense No- - Phone�� TYPE OF WELL/PUMP:. N L W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Vq FOUNDATION.- AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION:SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private3. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Publics , i� , M Other ❑ Delta Depth of Grout Seal Type of Grout I I.Irrigation —_Approx. Depth { I Eastern Surface Seal Installed by r. - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material (top 50') s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: ,NEW INSTALLATION ( I R/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res[dence ' Commercial— Other r Number of living units: l Number of bedrooms _ Character of soil to a depth of 3 feet: Wafer table depth = SEPTIC TANK ❑ Type/Mfg 1E. Capacity' 7 No. Compartments + PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest- Well -f. Foundation V Property Line LEACHING LINE & Length of lines"' "' Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation .— Property Line_- o SEEPAGE PITS I I Depth Size° Number SUMPS ❑ Dista n to nearest: Well 'Foundation Property Line DISPOSAL PONDS El I hereby certify that I have prepared this application and that the work will hJ done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heaiih'Dist&t. I ,J ,.i 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 shalt 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 les the followin ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la California." i + The applica caH for all eq t dins tion C pleswing on �alfers Signe ~ Tit Date- FOR DEPARTMENT USE ONLY Application Accepted by !� DateT, Stk., ea Pit or Grout Inspection DateFinal Inspection byDateAdditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621i ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. 201 FEE AMOUNT DUE AMOUNT REMITTED { INFO CASH RECEIVED 13Y DATE PERMIIT)NO. w EH13-24/REV.�in51 O l.J+� �� ►�J� �� f �7�•41�� CH 1420