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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 ,I 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 Local Health District. Job Address City f Lot Size 7 PM Owner's Name M2 Address `P, ! - Phone Contractorddress : N License No. /z Phone TYPE OF WELL/PUMPW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ir INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i-I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout__ r I I Irrigation --Approx. Depth [ I Eastern Surface Seal Installed by6U2!:� F?k/_ •� Repair Work Done ❑ Type of Pump _ H,P. 44 ", State Work Done �1 Well Destruction _>G Well Diameter Sealing Material (aeft-W) u depthIe Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 ❑ T e/Mf Yp 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 +� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 13 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line r SEEPAGE PITS I'I,_ Depth Size _,Number SUMPS ❑ Distance to nearest: Well Foundation Property Line (� DISPOSAL PONDS ❑ I 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. 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'gr sub-contracting signature ; certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject.to workman's compensa- tion laws of California." } „� The applica m r II re ons. Complete drawing on rqverg4 stde. Signed X "—� itle: - v Date:µ FOR DEPARTMENT USE ONL 4 _ Application Accepted by Date \2`i 3 - tea Pit or Grout Inspection by Date Final Inspection by Date t Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 399-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk CA 95201 AMOi]NT b'OE""'"`" AMOUNT REMITTkD �"CK —RECEIVEp BY` DATE T NO. INFO �f CASH PERMI t.EH 13-21(REV.1/n 5) S ,� �_ {• jf.� �r".� �� r EH 14-26