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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. � CfG� 01 Job Address � Cit Lot Size PM Owner's Name Address �'2P Phone d �� 01 L Contractor ddress 64(f icense No.r� Phone D TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT„❑ , _-DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER.0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ; M Public C1 Other n Delta Depth cif Grout Seal Type of Grout — i I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '� �- � state Work Done r Well Destruction Q Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted it public sewer is available within 700 feet.) Installation will serve: Ridence_ Commercial— Other e/� Number of living units: / Number of bedrooms� C_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity d No. Compartments PKG. TREATMENT PLT. ❑ r Method i _ of Dis I Distance to nearest: Well_i � Foundation � �� Property Line LEACHING LINE ❑ No. & Length of linesTotal length/size JJJf FILTER IED ❑ Distance to nearest: Well Y P Foundation D Property Line - 5— t SEEPAGE PITS I I Depth VS h* l! • Size mber y� LIMPS ❑ Distance to nearest: Well O Foundation Property-Line ISD POSAL PONDS ❑ 1 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 fallowing: "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 must 1 iQr 1 eq inspectio ss. CC pie drawing onrev ida, }� Signed X C/ (�y?�LG�fy Title: 7 Date: > I FOR DEPARTMENT USE ONLY / i Application Accepted by r ___1 Date / ` w Area 1� i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"/NO. +.EH 13-24 IAEya.i i n 5f 70-0 �1.40 EH t4-26