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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i M Telephone {209} 466-6781 r` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCornplete in Triplicate) 4' `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-7 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 d Lot Size PM Owner's Name&06d4Address Phond` � Aq . � / t Contras Address (-n O` Gl Licens ��/ Pho ' l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ d SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRO k FOUNDATION AGRICULTURE WELL OTHER WE ° PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC CIFICATIONS ❑ Industrial ;5 ❑ Open4Bottom ❑ Manteca o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack: ❑ Tra Type of Casing Specifications f7 Public ji a f 1 Other - Delta Depth of Grout Seal Type of Grout _ I i Irrigation r ;. Appr epth�""""I I Eastern Surface Seal Installed by _ ' - Repair Work Done ❑ T of Pump H.P. State Work bone k _ Well Destruction lr �} Well Diameter Sealing Material (top 50') Depth 'Filler.Material (Below 501 3 Y TYPE OF SEPTIC WORK: NEW INSTALLATION ['] 'f1EPAIRIADDITION I-I DESTRUCTIO (No septic system permitted if public sewer is 1 available within 200 feet.) G Installation will serve: Residence_ Commercial L. Other M Number of living units: Number of bedroomst 4 Character of soil to a depth.of 3 Leet: Water table depth O 5 •'�_ SEPTIC TANK �❑ Typelfulfglz =Capacity No. Compartments j PKG. TREATMENT PLT. ❑ n Method of Disposal istance to nearest:' " 'Well Foundation Property Line a t LEACHING LINE Cl✓No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well--- Property Line ' SEEPAGE PITS I I Depth Size Number r SUMPS Cl Distance to nearest: Well Foundation Property Line + DISPOSAL PONDS 0 I heieby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and y' rules and regulations of the San Joaquin Local Health District. Homeowner 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 applica must call for all requ re ins ctions. Complete drawing on reverse side. mm Signed X Title: /"�� Date: FOR DEPARTMENT USE ONLY Application Accepte:�y Date/() Area ! 7 Pit or Grout Ins ecti p Dat inallnspetby Dates" Additional Comments: L. �✓� ❑FStk 466-6781 ❑ Lodi 369-3621 ❑'Manteca a23-7104 ❑ Tracy Ed 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 W E AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE ///PERMIT'NO. + EH 13-24(REV.i i w 51