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APPLICATION FOR PERMIT \I-P SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA 1 Telephone {209) 466-6781 1 PERMIT EXPIRES 7 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 '/93(. wg-aaa Ade City S'� Lot Size PM x � Owner's Name � 1VI. "RAR AAt,4 Address 5.4 1 Phone SY � 'Contractor B Address S N L �- A/� AvE License No.41yS 1-"7 L Phone `lh,-C 39 7 + -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J PUMP INSTALLATION'❑ SYSTEM REPAIR El OTHER El 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 i ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications"( ❑ Public ❑ Other `❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION JK iNo septic systemithin emitted if public sewer is ]� Installation will serve: Residence Commercial— Other ava 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:a_' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth' s 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 1 rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies-the following:"'I C6MfV ttiat in the perforitWhee of the work for which this permit is issued, I shall not L laws of California."Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins tions. Complete drawing on reverse side. Signed y'�. �` Title: �� _ Date: �{ FOR DEPARTMENT USE ONLY \ ([S�C tL Date real Application Accepted by f- Pit or Grout Inspection by Date Y yFinal Inspection by �lDate f SitionaI Comments:. tk 466 6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,alicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO + EH 13-24(REV.1/8 5) _ �� 3-00 EH 14-25