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APPLICATION FOR PERMIT `x - %A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;,TON AVE., STOCKTON, CA ' Telephone (209) 466-6781 , PERMIT EXPIRES 1,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 weN/pump and the Rules and Regulations of the San Joaquin Local Health District. p �/ O O9"L / City Lot Size PVI Job Address Address r_1 13 o$ �43 r rf�1�_ Phone Z �� Owner's Name - Contractor h Address 11� �k cense No." Phone g 2��lCj TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ElIndustrial C1Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Hone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth e.- Filler'Material (Below 50') ► TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I. DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) OC Installation will serve: Residence Y__ Commercial Other COQI Number of living units: --I— Number of bedrooms , Character of soil to a depth of 3—feet- — - Water table depth SEPTIC TANK W":Type/Mfg CapacityUhkbfDn No. Compartments PKG..TREATMENT PLT. ❑ _ Method of Disposal. Distance to nearest: Well Foundation Property Line -� LEACHING LINE ❑ No: & Length of lines ,Total length/size r. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify thatI have prepared this application and that the work will be done'in accoidanee with San Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin Local Health District. ` 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 w 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." The applican must call for all required inspections. Complete drawing on reverse side. Signed X Tithe: �� r Date: 5 FOR DEPARTMENT USE ONLY ll Application Accepted by Date Area_t Date Final Inspection by Date '7��7 Pit or Grout lnspecti y ..y Additional Comments: � Aa/ ' ❑ Stk 466-6781 ❑ Lodi-369-3&i ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1fa01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 4 FEE AMOUNT DUE AMOUNT REMkTTED CASK RECEIVED BY DATE PERMIT NO. INFO C��7 + EH 13-24(REV.1?y 51 �+ /•3+11 EH 14 26