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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES '!'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(or Sewage or No. 1862 for welUpump and the Mules and Regulations of the San Joaquin Local Health Dis�pt. (,11'A2 Job Address /IJ. ��'//`rR�/�, City • Lot Size PM Owner's Name - 0 Address Phone 7!O/ A-41�--fl Phone � 7 '36 s Contractor Address � License No. TYPE OF WELL1P MP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ tf DISTANCE TO NEAREST: SEPTIC TANK 110 ' SEWER LINES DISPOSAL FLD. f i(] PROP. LINE L FOUNDATION AGRICULTURE WELL �OTHER+WELLT rPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION''- �wLL S1�'' q , ❑ Industrial Open Bottom ❑ Manteca Dia, of Well Excavation ---—Dia--of.-Well Casing `o a ]Domestic/Private t❑ ravel Pack C1 Tracy Type of Casing � �" 'v; Specifications )© Q � /f'l�Public €❑ Other ❑ Delta Depth of Grout Seal 00 Type of Grout_ I I irrigation,- _.-Approx. Depth I Eastern Surface Seal Installed by. Repair Work Done ❑ iType of Pum pe-OVork Dane Well Destruction CJ lWell Diameter Sealing Material stop i j r 1,Depth Filler Material. aw 50'I a. . t tr- s F TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION 1 I DESTRUCTION I l INo septic systefn permitted if public sewer is w t available within 200 feet.) E .Installation will serve: Residence— Commercial Other - �^•�•� - �-• .,, � � r Number of living units Number of bedrooms- 1 _ i 'F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: I Foundation Property Line 1 . , s LEACHING LINE ❑ No. & Lengt lines Total length/size' FILTER BED* ❑ Distanc' nearest: "' Well Foundation Property Line # SEEPAGE PITS i"I�Distah-eb-to-nearesu— th Size Number / SUMPS Well Foundation----- "Property Line" DISPOSAL PONDS ❑ f Y I hereby certify thaghave 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 Di?trict. Home owner or licensed agents 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 Califom'��' all for aft d ' a The applicant mu �nspes� r�mplete drawl ,on rave si k Signed X Title: Date: Z FOR DEPARTMENT USE ONLY plication Accepted by V A Date r Area Pit o Gro nspection bye -f• / - -� ate— Additional te Additional Comments: _ t ❑ Stk 466-6781 ❑ Lodi 369-3621 e❑ 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 r' FEE K 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. f� ! +.EH 13-24 111 EV.i/x 51 * `/T a i. [� EH 14-26 <,J