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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. j� �j Job Address M "/1Lr Peep- dally -- City 44tzl Lot Size _ � PM r Owner's Name rAddress Phone Contractor 01"' Address 7'.� License No. n�l Phone Z 2 TYPE OF ELL/PUMP: NEW WELL WELL REPLACEMENT 041. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑F 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 r. ❑ Industrial pen Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Reze Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal f Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done C7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50T ~� " Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 7 REPAIRIADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Watery table depth IF SEPTIC TANK ❑ Type/Mfg _ Capacity„ I No. Compartments PKG. TREATMENT PLT. ElF 2...I Me hod of Disposal Distance to nearest: Well Foundati 3n- "" Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation ry •`� I Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I 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. 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."Contractors hieing 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." c The applicant must all for all required in pections. Complete drawing on reverse side. Signed X Title: Ok>7'l" Date:L7 t7 FOR DEPARTMENT USE ONLY k - 4 i Application Accepted by _ 1 Q Date Area I Q Pit or Grout Inspection by ate r "Final s ction by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant eturn all copies to: Enviro mental Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, S2., CZA`%201 FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NQ. INFOjJf CASH 1 +.EH13-241REV.t/ns7 EH 14-26