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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ij (Complete in Triplicate) IApplication 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. 19 I ' Job Address ` City of Size PM ' I I �I l_/ / Q . I Owner's Name ! Q C- YI �C Address Phone / ` II Contractor� Sl J AddressLc.� L!!� License No. Phone I ITYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ISTANCE-TO-N EAR EST:�SEPTIC`TANK— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k C} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications M Public ❑ Other -4-1-Delta.,_,,,,. Depth of Grout Seal Type of Grout II I•I Irrigation r ;= ,Approx. Depth I 1 Eastern Surface Seal Installed by-, - :w _ . epa Rir Work Done El of Pump - """`"" �H.PState Work Done _ ell Destruction ❑ Well Diameter Sealing Material Ito_p 50', Depth Filler Material ( 'I 5011 n, i f t_ TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR IADDITION I, DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) r I � Installation will serve: Residence X Commercial_ Other I I Number of living units: Number of bedrooms Z� I Character of soil to a depth of 3 feet: Water table depth EPTIC TANK ❑ Type/Mfg -' `C p city No. Compartments 'PKG. TREATMENT PLT. ❑ F ""' '� 'Iti7Eethod of Disposal lDistance to nearest: Well Foundation Property Line C M • •1 1 1 I - LEACHING LINE ;K No. & Length of lines �G+� �� Total length/size FILTER BED ❑ Distance to nearest:—Well'• .- _ ^_Foundation—/_D/ 'Property Line 1 49 SEEPAGE PITS I I Depth Size _�'IVumber - ' 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 iignature 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 this permit is issued, I shall employ p&sons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ~� I I i � l 14 STitle: ( Data: l it FOR DEPARTMENT USE ONLY ]Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 5'� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 171 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Ratum all copies to: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009,�Stk., CA 95201 1 I I INFO AMOUNT DUE AMOUNT REMITTED." -�A$ . -- - RECEIVED-BY �'`�"'-D'ATE ""�PERMIT'TFO i. EH 1 4 -28 S