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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1641 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 e 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 Local Health District. Job Address u/: City Q�� ru Lot.Size oto PM Owner's Name U f IAddress� ^ �� s Phone 3 Contractor �'� Y Address u ;V License No. _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation - Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ^ ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 1� Repair Work D El Type of Pump H.P. State Work Done ► Well ruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z- Z Commercial_ Other l i Number of living units:_ Number of bedrooms b Character of soil to a depth of 3 feet: 0 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 lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 .:z SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property 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, 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." t mus call f r all requir inspections. Complete drawing on reverse side. Signed Title: yw.n Date: FOR DEPARTMENT USE ONLY Q �j Applicatiori Accepted by Pate VAN Area Pit or Grout Inspection Date Final Inspection by Dates Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 3621 ❑ Manteca 823 ❑ 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 REMITTEDA RECEIVED BY DATE PERMIT'.NO.' INFO ^'� + EH13-241REV.i/85Y � .-V� ? �� EH 14-28