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t r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 well/pump and the Rules and Regulations of the San Joaquin r Local Health District. -1 M -}�i Job Address Ch 6 p oks6 City S s r`"�!A Lot Size ` PM Owner's Name �hE��O1"'� Address Phone �p i f I Contractor Address S� License No.y 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ ar 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 ❑ Industrial LJOpen Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel.Pack ❑ Tracy Type-of•Casing= Specifications k n Public ❑ Other IF] Delia Depth of Grout Seal ` Type of Grout I I I Irrigation -r.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ � F Well Destruction ❑ Well Diameter Sealing Material 6-0p.50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION i,I DESTRUCTION septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other s 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 s 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 I i Depth Size Number i h 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 rules and regulations of the San Joaquin Local Health District. I M Home owner or licensed agent's signature certifies the following: '('certify Mat-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."Contractors hiring or sub-contracting signature dies the followin "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 of Califor >r The applic ust ca 1 r io.. omplete drawing on ersgrsi Signe Title. Date: FOR DEPARTMENT USE ONLY (AI Application Accepted by Date` Area t Pit or Grout Inspection by Date Final Inspection by� Date l �ditional Comments: t Stk -4 6'6781 —0 Lodi' 369-3621 ❑ Manteca a23-7104 �❑ Tracy 835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK r FEE AMOUNT DUI: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH13.24UIEV.tik51. -'y EH 14-2a O