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APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT N�L3 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-678t PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 ^ City �+� Lot Size PM � Owner's Name Address Phone � Contractor Address License No. Phone 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 I 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 E] Domestic/Piivate"— L] Gravel Pack E3Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.ApproK. Depth I l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION is DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) a Installation will serve: Residence__`—Commercial_ Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: �- "� r r- Water.table depth SEPTIC TANK 0 Type/Mfg Capacity g No. Compartments PKG, TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Wel! Foundation = { Property Line r s LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation r v Property Line SEEPAGE PITS I i Depth ; Sizer Number SUMPS 0 Distance-to. nearest: Well Foundation --Propertyty Line 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, andl� rules and regulations of the San Joaquin Local Health District. r 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 follow- : '9 rtify 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 Calif r The applicant s r all rerequired inspections.-Complete-drawing on-.reverse side. Signed Title:-Mai ~Date: 1 FR DEPARTINENT USE ONLY { { Application Accepted by � �36.�ws.�w(1JMw� T-- Date �3 Area L ` Pit or Grout Inspections Date l Inspectio b / Data " I c� I Additional Comments: r'"f OILY n 1 r -7 ` I ❑ Stk 456-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ! INFO CASH I4 rEH13.24IREV.1in51 ffSC� � �-�-`' �(� �� 87 -332 - EH 14-28 !