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I „t APPLICATION FOR PERMIT �� + SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 R Zzv�� PERMIT EXPIRES TYEAR FROM DATE ISSUED N0 v:, (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 des ribed. 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. t Job Address _�'� �(/� ' ,z'! City ° Lot Size PM Owner's.Name Address � A Phone I Contractor rf Address License NoA4'14' one k TYPE OF WELL/PUMP: jNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE FOUNDATION AGRICULTURE WELL_ ELL t. PITS/SUMPS _ r 'INTENDED USE r TYPE OF WELL PROBLEM AREA 'ICON ION-SPECIFICATIONS:, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing J '+ d� D Domestic/Private ❑ Gravel_Pack acy Type of Casing Specifications fii'Pubtic 1711Other ff Cl Delta Depth of Grout Seal Type of Grout — I I krigation _--Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Do Type of Pump �" H.P..- - - - - State Work.Done Well D ction ❑ Well Diameter Sealing Material Itop 501 ° z I Depth l Filler Material (Below 501 r . t TYPE OF SEPTIC WORK: NEW INSTALILATION I I REPAIR/AODITION 1.1 DESTRUCTION I (No septic system permitted if public sewer is f �" available within 200 feet.) I Installation will serve: Residence Y 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 � r PKG.-TREATMENT PLT. ❑ Method of Disposal 1 a� r 'r, Distance to nearest: Well Foundation Property Line (� 4 LEACHING LINE ❑ No. 8 Length of lines ° [ " � ~Totat length/size O 111 FILTER BED ❑ Distance to nearest: Well r Foundation Property Line b x l 4, - i. SEEPAGE PITS�p I I Depth Size Number SUMPS Ll Distance to nearest: Well 'Foundation Property Line r DISPOSAL PONDS ❑ _ I hereby certify that I have prepared tkiis 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 "`^ 4 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,riianner as to become subject to workman's compensation taws of California."Contractor's hiring,_otFsub;contracting signature certifies the following: "(,certify that in the performance of the work for.which.this permit.is.issued,-i.shall employ peirsons subject'to workman's compensa- tion laws of California.";. '""4" [ - T icarit must call f�all �', ins�pEKti . Complete drawing onreversestd /^ ,� _ II Signed X Title: f® ' Date: �— � A DEP EfVT USE ONLY ' `-f Application Accepted by4 TeX& Data �` Area Pit or Grout Inspection by Date Final Inspection by - Date —� I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Wanteca 823-71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box-2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED (CK RECEIVED BY DATE PERMIT- INFO + EH 13-24(REV.rrn5) EH 14-26. t�