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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTR r,�X ��,�' 1601 E. HAZELTON AVE,, STOCKTON, CA 1� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ItJ 2 k (Complete in Triplicate) ENVIROMLNTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workFRRMPbM nIipplication 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.' 1 r =d Job Address ''' City Lot Size PM Owner's Name �A�C'.�t_. .ltYwa�. Address e44&1Mn&= -- Phone y � ContractAddress License NoP42—Phoney�-2—�l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FIA PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �❑1Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing 14—Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications I M Public CI Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth t I Eastern t Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. l]r _ State Work Done i Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 'y 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 + LEACHING'LINE ❑ No. & Length of lines Total length/size l FILTER BED .'. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS '� l 1 ,Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS y. ❑ 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. .» 1 , 'Home owneror 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 i :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,1 shall'employ persons subject to workman's compensa- tion laws of California." + 1 � The applicant m II or all required inspections" Complete drawing on reverse side.- Signed Title: — {9_j Date:?—_ QR DE pu MENT USE ONLY �-y f, Application Accepted by �/� Date r —2— 1 ~�a Ar o �77 Pit or Grout Inspection by Date Final Inspection by Date2 a`L1 Additional Comments: 11 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 .I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIYNO. ..- a EH 3-241REV.t/A51 f 17, �EH 1 - [j