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f s APPLICATIOWFOR PERT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 46626M. 4-)o 1& 3 VAC 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 es T� Ld- C Lot Size PM - - r Owner's Name Address Phone ' y7 .,> 7 4 Contractor's Name MO r? ►vl Q S&P License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION *r' SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST:-SEPTIC TANK L--_- SEWER LINES - -DISPOSAL FL-D. —PROP.-LINE= -- . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS mow, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 �❑� In��dustriaf ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing €'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump"!:ik Ig H.P. State Work Donee, Well Destruction ❑ Well Diameter '1 l .. Sealing Material (top 50') + Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION q (No septic system permitted if public sewer is Installation will serve: Residence— Commercial, Other available within 200 feet.) , k Number of living units: Number of bedrooms PAYMENT Character of soil to-a depth of 3 feet: Water tables! r SEPTIC TANK F-1Type/Mfg Capacity No. Compg� is I PKG. TREATMENT PLT. ❑ Method Distance to nearest: Well Foundation Property LinCANJOA�UN C010NrTY IC EALTH SER1FIti:'' LEACHING LINE ❑ No. & Length of lines' Tota! length/siAVIRON€V1ENTAL HEALTH i)1'r;v.�i FILTER,BED ❑ Distance to-nearest: Well Foundation Property Line SEEPAGE PITS t ❑ Depth -S ize Number "—SUMPS- w EI-"-Distance'to nearest: Well - - Foundation pro ' - 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 t 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 F 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 iaws of California." The applicant must call for all required inspections. Complete drawing``onn�reverse side. Signed Title:,k/, �,� �i�Y Q�.. r Date: . >' FOEPA RJ IINT US NLY Application b Accepted 7 p y Date p �-F Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 S FEE AMOUNT DUE AMOUNT REMITTED INFO �y�� A �i RECEIVE[}BY DATE PERMIT"NO. + EH 1428 EH 3-24(REV.101831 _ r r/(/ i �7' r>�