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Q APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1 1' Telephone (209) 466-6781 t PERMIT EXPIRES 1 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District. City S775G of Size 4 PM Job Address ZZ ! /f 0� 5 �� Address �; �� Phone Owner 's Nam ' Contractor Address License No. Phone_ + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ '-OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WEL'L� PROBLEM AREA CONSTRUCTION SPECIFICATIONS-.t . �\ it ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing Qe El Domestic/Private ❑ Gravel Pack•. ElTracy Type of Casing Specifications 17 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — 1 1 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by ' Repair Work Done LlType of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 50') stem perm TYPE OF'SEPTIC WORK: NEW INSTALLATION I� REPAIR/ADDITION 1 1 DESTRUCTION' (No ! ilab etlw thin 200 feeti1)ed if public sewer is Installation will serve: Residence, Commercial— Other { Number of living units: Number of bedrooms 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Vines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS l I Depth # ,Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL-PONOS ❑ F I hereby certifq that I have"-prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of1he 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,.) shall not tl 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 followin 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 Calif 1 The applicant for all req inspections. Complete drawing on reverse side. Signed Title: Date:. 42 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection by Date —Fe Additional Comments: /� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L" [tv rQr G� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /Qv4. I FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE RA [�i + EH 1 3.24(REV.1/n 51 EH 1426