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ry E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 'u— VL4` PERMIT EXPIRES'1 YEAR FROM DATE ISSUED ire— (Complete.•in Triplicate) 1�, Application is hareby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r rmade 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 -_� I-10 L � City a Lot Size PM - Owner's Name l Address Phone Contractor ,rl �Address� c�G License No Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V ❑ Irrigation 1i' . �pprox. Depth Eastern Surface Seal Installed by Repair Work Done Type of Pump 5 H.P. Sime Work Done i �' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No•septic system permitted if public sewer is U available within 200 feet.) V ' Installatioh 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`" * " "" CapacityNo. Compartments PKG. TREATMENT PLT. Ll �'. y •* Method of Disposal Distance to nearest: Well t. Pounoperty Line r . ,-LEACHING LINE ❑ No. & Length of lines � � �' Total length/size " FILTER BED 3 ❑ Disiance to nearest: Well Foundation +.: __,P.roperiy Line SEEPAGE PITS ❑ Depth Size r Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 t 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 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 o la." The. plicant � tali for all�re ired insp ions. plete drawing on se side. rSigned X r Title: `f 5 Date: �/,; S F P DEPARTMENT USE ONLY �I Application Accepted by r Date 1—c��' Area � l Pit or Grout Inspection by Date Final Inspection by 2/�! Date ZS Q Additional Comments: ❑ 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH. , RECEIVED BY. DATE PERMWNO. + EH73-241AEV.1�FSl �� / "�^ ( �'�( r��(' �•�.i.