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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone MSI) 466-6781 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 HeatDistrict.COZ3a .. Job Address Q City / G Lot Size PM I Owner's Name Address Phone Contractor ,54ddress License No. el Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ 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"° 1]5=Manteca—Qia�of"Well-Excavation—`- --Dia7-of-Well-Casing-" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 1-1 Other -3❑ Delta, Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth .i' Eastern �' Surface Zeal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction Well Diameter Sealing Material [ p 0 7ZE �d Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is p available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Y Cappc .. :'�, No. Compartments t� PKG. TREATMENT PLT. ❑ Method of Disposal V`} Distance to nearest: Well Foundation 3 Property Line LEACHING LINE ❑-=o. & Length of lines Total length/size FILTER BED ` ❑ .Distance to nearest: # Well', y Foundation Property Line SEEPAGE PITS 11 'Depths" x Size`� " Number SUMPS D Distance to nearest: Well }ti 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 s 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 parson in such manner as to beco`me'sub' tri 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 applica S r 11 re ' ctions.�Comple�tedrawingn on r ve a side. Signed X Date: 4 1 tke s .0- NL �1FO. R DEPARTMENT,USE-O t-y, L , Application Accepted by Data y Area ^� Pit or Grout Inspection by Date Final Inspection by Date l I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MS Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED BY DATE PERMIT'NO. INFO CASH ♦.EH13.24(REV.I/K5) ' T.. �� rS � �V � -- • �° EH 14-26 - = f1 f