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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �p�G4' �>\a�'N 1601 E. HAZE I ON AVE., STOCKTON, CA `r Telephone (209) 466-6781. R PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L -(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 descFibed.This application is I • made in compliance with Sari 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 –� �' City Lot Size PM r Owner's Name Address te. � Contra ctorAA0 Address r*/r -2 4 License No. Phone _4111 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR/N OTHER Lily, 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LI Manteca Dia. of Well Excavation Dia. of Well Casing tt Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Ll Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by " Repair Work Done F Type of Pump A aAll- H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0% 'DESTRUCTION-CIANo septic system permitted if public sewer is t _ 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: k 4 r Water table depth SEPTIC TANK C. Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ •4wy Method of Disposal Distance to nearest: Well Foundation Property.:One LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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. x ! Home owner or licensed agent's signature certifies the following: "I certify thafin the p6F–which -performance of the work fthis 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." ;, s The applicant st II f required inspections. Complete drawing on erse..side. Signed Title: �^'+�'f+"r – Date: Y FO ENT-USEONLY / Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection bi-� Date �/ { Additional Comments- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83643M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMMITTEOCK#J RECEIVED BY DATE PERMIT`NO. INFO + EH13-24/REV. EH 11/95) , O(} 426 r' •:in„