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` a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 ' PERMIT EXPIRES 1 YI_AR FROM DATE ISSUED (Complete in Triplicate) iI 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. �y ��}ry,, Job Address CA rC / City C T,lLnt Size PM Owner's Name y tt�'�� Address � �� rem(_e Phone Contractor S$ C r!q z Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPT TANK SEWER LINES DI AL FLD. PROP. LINE 'I FOUNDA N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE PROBLEM AREA TRUCTION SPECIFIGATIONS f ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delt Depth of Grout Seal Type of Grout I i Irrigation _AP Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Ty of Pump H.P. State Work Done y .. Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other r 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 o Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 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, andv 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t 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�/ � require ssJpecti�s. Completedrawing on reverse side. Signed X_ � �ti,.-__cry--d'1-_ Title':" Date: 3"l, FO DEP TMENT USE ONLY I Application Accepted by Date �� Area r( Pit or GroutInspection by Date Final Inspection byDate ! / Additional Comments: - V.D _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I 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 CK_* RECEIVED BY DATE PERMIT-NO. +.EH 1 3-24(FI EV.i r 5) 3-5, EH 10-2e 1 I