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APPLICATION FOR PERMIT ;+ # SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 f 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 '1 Local Health District. Job Address � 6 City Lot Size � (y PM 'Owner's Name lS/ r'°""� `� rn Address �'� Phone °' 7� • 66 �`Qa1 L-icense No. 2/phone T4'— Contractor� - ddress TYPE OF WI=LL/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— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack v ❑ Tracy Type of Casing Specifications t hl Public Cl Other F1 Delta Depth of Grout Seal Type of Grout F I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done L3 Type of Pump H.P. State Work Done _ I Well Destruction ❑ Well Diameter Sealing,Material (top 50') ` Depth Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION L.) DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_.r Other . f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/MfgCapacity- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ' ❑ I hereby certify that I have prepared this application avid 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 sigriature 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 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 applicant must calll four.all requi5ad inspections. Complete drawing on rave a side, �f i SignedX ) Title: Date- / VJ I FOR DEPARTMENT USE ONLY o,3 Application Application Accepted by Date Area z Pit or Grout Inspection by Date R al Inspection by ate 1 _ Additional Comments: ❑ Stk 466-6781. ❑ Lodi -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 r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMfT_NO. + EH13-24iR EV.1/Hsl EH 14-26 w {