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r S S APP4ICATI(-N FOR PERMIT max: SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE.,-STOCKTON, CA ° P Telephone (209) 466-6781 e PERMIT EXPIRES-1 YEAR FROM DATE ISSUED_ 1 (Complete in Triplicate). ;, -�Sv OLS -S Er i . 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. Job Address City Lot Size 5' PM N y . .. E i- _-s 7 G Phone »r d �✓< � � Address � ��o� ' Owner's Name i !� Address License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION 1:1 l PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER,❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE s FOUNDATION AGRICULTURE WELL OTHER V11ELL' t: � PITSISUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ❑ Open Bottom Ll Manteca ❑ Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications---- i^ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ID Eastern... Surface Seal Installed by Repair.Work Done LlType of Pump t H•P• State Work Done Well Destruction ' ❑ Well Diameter Sealing Material (top 501 Depth ' Filler Material (Below 50'1 . p TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION Elava DESTRUCTION septic system permitted if public sewer is a available within 200 feet-1 In will serve:"Residence_ Commercial_ Other t, Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: -- ` L k Water table depth } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments__ _ [ PKG:TREATMENT PLT. ❑ Method of Disposal ` [ '' Distance to nearest: Well Foundation Property Line 1 R Total length/size LEACHING LINE ❑' No. & Length of lines . Property Line FILTER BED ❑ Distance to nearest:. i Well Foundation P HY SEEPAGE PITS Q Depth ; - Size Number SUMPS ;❑ Distance to nearest: Well Foundation Property Line {. DISPOSAL PONDS ❑ { 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."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 applicant ust call for all required inspections. Complete drawing on reverse side. r Signe¢ y I Title: Date: �JJ � FOR DEPARTMENT USE ONLY '] ♦. Date [' Area Applica on Accepted by �. y Pit or Grout Inspection by Date Final Inspection by Date d�/ Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 -❑ anteca - 1�- CEI�Tracy�835-63MSS 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 CASH RECEIVED BY DATE PERMIT NO. O INFO" + EH 1241REV.1/95) - +y - w -...r s. EH 144-28