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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT -, i 1601 E. HAZE.T ON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i 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. V q Job Address -s �6� C.t✓i�AS�1 rV4 14l�J City S OLKL-0- Lot Size 60 k ` –PM Owner's Name Address Phony Contractor �l` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/PriJate CJ Gravel Pack C1Tracy..,;_,_ _.--Type of.Casing Specifications {ti I'1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout v� I 1 Irrigation —.Approxi Depth l I Eastern Surface Seal Installed by Repair Work Done .0 . Type of-Pumrp H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 (� TYPE OF SEPTIC WORK: NEW INSTALLATION I.1, REPAIR/ADDITION I 1 DESTRUCTION 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 t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ _ Method of Disposal Distance to nearest: Well w. Foundation_ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property line SEEPAGE PITS I I Depth I 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 l rules and regulations of the San Joaquin Local Health District. 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 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 thisermit is issued, I shall employ tion laws of Califor a. p p Y Persons subject to workman's compensa- tion 1 The applicant m s call f ail re uired spections. Complete drawing on reverse side. �+ X Signed X Title.. Date: Q 1 FOR DEPARTMENT USE ONLY Application Accepted by Date �~ 27 8�2r Area Pit or Grout Inspection by )! Date` Final Inspection by Date Additional Comments: —�f�i 5- {� , G s a U 7^'. 7_ 4> _ C 1�L� ❑ Stk 466-6781 ❑ Lodi 36.9- 1 ❑ Manteca/ 823-7104 ❑ Tracy 635-fi365 '"`� TT Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. b+szeellton/Ave., P.O. Box 2009, Stk., CA 952 1 S.SFEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK 0 RECEIVED BY DATE PERMIT NO. ♦ EH 13-241REV.tiH51 EH 14-2e �J