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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT , 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone (209)466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,,- (Complete SSUED ,(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.' +r Job Address !(/, City Lot Size PM Owner's Name +/ Addresses Phone J T t. p Contractor ess License No.�Phone? 0 T /r712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _PUMP-INSTAL-L-ATIGN-,7 ---+------W---SYSTEM-RE PAIR'"❑ THEA' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR P� O Ll N� i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM tAREA- CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca �Dia. of Well Excavation- Dia. of Lhe11 a§ing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac T e of .i F Y yp Casing .� � Specifications ❑ Other ❑ Delta ❑ Public t� p Depth of Grout Seal " t Type of Grout ❑ Irrigation _. _._Approx.iDepth ❑ Eastern Surface Seal Installed 15yf Repair Work Done, ❑ Type of.Pump H.P_ — StateWork Done Well Destruction 0 Well Diameter Sealing Material Ltop 501 d Depth I _ Filler Material (Bejoyv_50'L _ . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITI ❑ STRUCTION INo septic system permitted if public sewer is "� available within 200 feet.! Installation will serve: Residence Commercial (.O`ther Number of living t:'units: Nu ber of bedrooms Character of soilito a depth<of 3 feet: !, ! Water table depth SEPTIC TANK Type/Mfg Capacity p y 1 No. Compartment- i PKG- TREATMENT PLT. E1i s it L Method of,Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE }❑ 'No. & Lentthr r� I g of lines + Total length/size ' FILTER 8ED ❑ Distancei to nearest: Well Foundation-^ a Property Line I # FI SEEPAGE PITS Q Depth 1 1 Size Number SUMPS e - Distance/to nearest: Well. Foundation Property Line DISPOSAL PONDS ❑ ,� j I hereby certify that I have prepared this application and that the work will be done in accordance wish San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed aaent'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 personin suchmanner as tQ become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i Certifies the following: "I Certify that in i e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican mus calf 1P all -aqui inspections. Complete drawing on reverse side. Signed X/417* Title: Date: _2-C-4 FOR DEPARTMENT DEPARTMENT USE ONLY Application Accepted by �' t ' Date_ 5—�` Area U� Pit or Grout sjiectioh v� Date Final Inspection by Date r Additional Comma ii ❑ Stk 46616781' ❑ Lodi 369-3621 ❑ Manteca 8,213-7104`, t ❑ TracyM 835-6385 Applicant Return all copies to: Environmental Health-PeI'mit/1 e86„es 1601,'E. Hazelton Ave., O Box 2009 Stk., CA 95201 FEE AMOUNT DUEf AMOUNT REMITTED CK 37— INFO RECEIVED BY ii CASH DATE PERMIT'NO. { '+hEH1 -24SREV.s/esy EH 1426 �l-