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FAPPLICATION FOR PERMIT f — SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE-, STOCKTON, CA 1� Telephone (209) 466-6781 t PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. I Job Address � � /"r �t� -- r v City �.ya Lot Size PM Owners Name Phone �2 Contractor Address�7Ir�?/� li'cf� X ZPLicense No, 6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom IDManteca Dia. of Well Excavation Dia. of Well Casing 4� k ►Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f'dSpecifications 1-1 Public ❑ Other 11Delta Depth of Grout Seal Type of Grout O'Dj I.I Irrigation o��Approx. Depth l I Eastern Sur ace Seal Installed by C/71y- _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Materia! (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION f I (No 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line BLEACHING LINE ❑ No. &length of lines Total length/size b FILTER BED ❑ Distance to nearest: Well Foundation Property Line Al 1 SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line F 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 Di%trict. 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 applieani t r 11-te� tions. Complete drawing or) rVerse side. Signed X Title: �✓T'/ Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date f Area Pit or Grout inspec ' b �z 1 Date Final Inspection by Date I � t Additional Comments: t✓l ft` is G Ct T�ri r ✓r�( i�� 5[ r`�-f ' ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. i ff-oda tr'/ r.EH 13-24(REV.t/H s) F EH 11-26 106