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„ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "y`..C! (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 Addresses _ City Lot Size PM T Owner's Name --Address C, Contractor's Name icense No. �- Z_ Phoned TYPE OF WELL/PUMP: ' NEW WELL D WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.iVEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER_ti'VE_LL PITS/SUMPS I 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_ Specifications ❑ Public ❑ Other D. Delta Depth of Grout Seal . Type of Grout El Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done '.,CO Type of Pump H.P. �� State Work DoneE , Well Destruction ❑ Well Diameter Sealing Material {top 501 00 Y f = Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is m available within 200 feet.) Installation will serve: Residence— Commercial— Other— .Number ther.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. [IMethod 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F1 _ 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."Contractors 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 call or all required inspections. Complete drawing on reverse side. Signed '� �--`` Title: Date: `CJ"-' FOR DEPARTMENT USE ONLY b ; Application Accepted by.. Date Area497 Pit or Grout Inspection by Date _* ` Final Inspection by Date 10 cw-.b Additional Comments: - i l IAK-, -7-to--0- s ❑ Stk 456-6781 ❑"Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 5 85 Applicant- Return all copies fo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ffkT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0, CASH+EH 13-24{REV,10183] �"� rEH 1426 y !