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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE T ON AVE., STOCKTON, CA r Telephone {209} 466-6781 PERMIT EXPIRES 9"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. .. r L• Job Address City Lot Size�7 PM Owner's Nam �C1J- — /jess � �� i� Phone Contractor Address + License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1711 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINESDISPOSAL 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 1 Dia. of Well Casing ❑,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' FI Public 171 Other Cl Delta Depth of Grout Seal Type of Grout E I Irrigation --Approx. Depth I i Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth ' Filler Material (Below 501 X ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I Mo septic system permitted-if public sewer is r� f i ' _ - • available within 200 feet.) 4 "` t r"t Installation will serve: Residence Commercial Other" � (",.1 f Number of living units: Number of bedrooms Character of soil to a depth of 3 feetw' f Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well.; "T Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well "Foundation # � ?�� Property Line SEEPAGE PITS : I 1 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, 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 riot 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, E shall employ persons subject to workman's compensa tion laws of California," 1� The applicant must call for all require ins tions. Complet . rawing on reverse side. Signed X ry / Title: Date: S� t AA�" FOR DEPARTMENT USE ONLY ^ pplicatian Accepted by . Date Area I e • � ,r Pit or�Grout Inspection by Lnt.-a e Final Inspection by Date -ok3,q Additional Comments: 1 �- �t/ / I ❑ Stk 466-fi7$1 La ' 369-3621 ❑ 823-7104 ❑ Tracy 835-fi385 - L Applicant Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK J INFO jjj�� CASH RECEIVED BY DATE.- PERMIVNO, '+ EH 13-24{REV.i i N sl `J EH t4-2t3 ` - r