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/�2apti-i��,ric,ompliance APPLICATION FOR PERMITSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA �Telephone (209) 466-6781' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED(Complete in Triplicate)n 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 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 J C� NY El rr �/� City S Lot Size PM Owner's NameaP�fl/!sl�� "l�yf -> -� Address .JL�L� `��/�� t / � 1�phone Contractor :, __Address., �� ` �d L,S�L.J Li No.Z,�v__�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'A t 'SEWER LINES DISPOSALFLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �.x ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of_Weli Casing A t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingµ Specifications ❑ public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.` State Work Done_ a Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION XDESTRUCTION'E] (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: Water_.table.depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal., . Distance to nearest: f Well Foundation .Property Line 3 ` F f LEACHING LINE No. & Length of lines` Total length/size i FILTER BED ❑ Distance to nearest:,/ Well Foundation PropertyLiner f I i SEEPAGE PITS ❑ Depth 6d`06Z/ Size , J Number V SUMPS LlDistance to nearest: f Well ,Foundation j Property Line DISPOSAL PONDS ❑ 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. ' I P , 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 this permit is issued,I'shall employ persons subject to-workman's compensa- tion laws of California." - - - V • - , .- ----t The applicant must call for required inspe io Complete drawing on reverse side. i Signed XT 7/ tle: _ , Date: FOR DEPARTMENT USE ONLY Application Accepted by !� � Date ! Area Pit or Grout Inspection by Date �w4 Final'Inspection'by �'' DateO Additional Comments: ' '' T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 �, E] Tracy 835-6385-1, -y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. +EH (REV W25 EH 1428 !