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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ¢ Telephone (209) 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 Health District. Job Address k' City 61 Lot Size K PrPM Owner's Name Address Phone ` Contractor's Name License No/(0�` Phone ,TYPE O.F_WELL/_PUMP:.r„ ,..NEW WELL.G�!' '. :`1WELL-REPLACEMENT.❑ ._ DESTRUCTION-0 PUMP INSTALLATION C� SYSTEM REPAIR ❑ OTHER 171 ti DISTANCE TO NEAREST: SEPTIC TANK /dam SEWER LINES I xv DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ".� OTHER WELL PITS/SUMPS 1 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F �� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati 00FO Z, Dia. of Well Casing r lefomestic/Private aGravel Pack ❑ Tracy Type of Casing Specifications ClPublic ❑ Other C1 Delta Depth of Grout Seal �r ' Type of Grout Z_ ❑ Irrigation --Approx. Dept ED tern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 �` } Depth/•fin Filler Material (Below 501 `�'� C ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t e+ ,fi 1 available within 200 feet.) r " Installation will serve: Residence— Commercial_Other_ w k Number of living units: Number of_bedrooms ,df Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg lief Capacity y No. Compartments PKG. TREATMENT PLT. ❑ JJ �` ;; `„ Method of Disposal Distance to nearest:. Well Foundation �A " ;.Property Line [ LEACHING LINE ❑ No. & Length of lines !' �� +` -=TotAI length/size FILTER BED ❑ Distance to nearest: JV1]ell Foundation.*- Property Line Q SEEPAGE PITS ❑ Depth __ Size Number(.` r SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + If 1 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,164uin Local Health District. 1, - 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 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 st call for all re ed inspect( S. Complete drawing on re side. Signed le: i Date: FOR:,DEP RTMENT USE ONLY Applica6on.Accepted.by.r--. - - ---- .- _. _._._ .: -Date. �.�_... rea - Pit o Grout spection by Date ' _6;W Final Inspection by Date u/ .' Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F Ay FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY j DATE PERMIT'"NO. INFO + EH 1324(REV.10183! . 1 ,or$ EH 14-28