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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) 7 A t Application is hereby mads 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. t �` ./ / e." _ rT , r2 City Lot Size PM Job Addiess v j fL r r '�` ®[/ �D Phone Owner's Name ddress r p I + Contractor Address ansa No.I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA(!EMENT ❑ DESTRUCTION ❑ t 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 I i{ ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 111 ❑ Public M Other Cl Delta Depth of Grout Seal Type of Grout ._ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material {Below 50') ! s TYPE OF SEPTIC WORK: .NEW INSTALLATION tff REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is x available within 200 feet.) �J Installation will serve: Residence Commercial-Other t 4y Number of living units: --I— Number of be oms (j # ii Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG, TREATMENT PLT. ❑ / Method of Dis sal Distance to nearest: Wellr r�Q Foundation Property Line LEACHING LINE ❑ No. &.Length of lines ��`� f Total length/size FILTER BED. 11 Distance to nearest: Well L9 t2 Foundation -!2 Property Line SEEPAGE PITS I I Depth Size " i' f T r Number SUMPS L] Distance`to nearest: Well Fourifdation Property Line DISPOSAL PONDS ❑o I hereby ct rtify'that I have prepared this..application and that the`vvork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of th'4lSan Joaquin Local Health District't °•� 'Home owner or licensed agents signature certifies-the following: "I certify that in the performance of the work for which this.parmit 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 I certifies the following: "I certify that in the•perf ormance of'the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of<California." The applicant rrwst call for requi d ins ctions�Comple drawing on reverse side. v ' Signed I / Title: _" Date: U r. g •; FOR DEPARTMENT USE ONLY I Application Accepted by Date p. Pit or Grout Inspection by __ rf Date Final Inspection by Oate / Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 d Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24 1REV.I/H 5) - 1 EH 14-2e 47