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gr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 41STRICT 1601 E. HAMILTON AVE., STOCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ti 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/ and the Rules and Regulations of the San Joaquin Local Heal District. (/ glJ �il 'li` I t� 1�•c!J City L� Fill) Lot Size PM Job A ress _ f Owner's Name Address Phone _C_ontractor d1 Address-3,50_ _ ca-- _ icense Nao. EX Phone C/ 5 �— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES--_QISPOSALLS F ._. _ i_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ` PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation'" Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s 4 i' Specifications ❑ Public ElOther ❑ Delta Depth of Grout Seal r Type of Grout 4 = r ❑ Irrigation _"—Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material Itop 501 N Depth Filler Material-{Below-50'! f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public'sewer is available within 200 feet.) h Installation will serve:Residence CommercialR[Other _— +T ._ c� ; ', d1 Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: r ;, Water table depth t (� SEPTIC TANK &--Type/Mfg , Capacity 1 x.00 No. Compartments iF�i mitis, PKG. TREATMENT PLT. ❑ _ — .. `' > i Method of ispossal i Distance to nearesf:"""""Will" Foundation- 110, Property Line LEACHING LINE D-INo. & Length of lines _,;L Total length/size FILTER BED ❑ Distance to nearest: Well JO-0 Foundation Property Line R SEEPAGE PITS &.�Depth Size3 Number dd t r BUMPS ❑ 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. I k 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 shat!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 I certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion la of Californi The applicaLJ ca for all require specti to drawing on reverse side. 4 Signed Title: Date: e r FOR DEPARTMENT USE ONLY Application Accepted by bate jaAArea I Pit or Grout Inspection by Date Final Inspection by Date A ditional Comments: Stk 466-6781 ElLodi 369-3621 C7 Manteca 823-7104 ❑ Tracy 835 A6385 A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,.,,CA 9520„_, r,-- �— -- - —FE AMOl1NT-Ot7E'— —AMOUNT'REMITTED �� RECEIVED BY DATE PERMIT NO. INFO �� Cb b b1 ' + EH 13,24[REV.f/B5) EH 14-25 .1 �