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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -' Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSI�J (Complete in Triplicate) r'' �Y Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t env�f_ in.de btfd is is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well pump and the R6le }n�1 Pgut9 s'o Ohs San Joaquin Local Health District. r� ` City Lot Size PM Job Address (/ Owner's Nam6hd OL Address _ Phone 3 Contrac or !Zs Address License No'' Phone 4:1y__57 TYPE OF WEL"L/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDER USE TYPE OF WELL PROBLEM'AREA " CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing ❑ Domestic/Private '❑ Gravel Pack- ❑ Tracy Type of Casing Specifications l-1 Public ❑ Other I--] Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done E3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 Depth ller Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ DDITION DESTRUCTION l 1 INo septic system permitted if public sewer is (/% available within 200 feet.) Installation will serve: Residence_ Commercial_ Other I Number of living units: - I— Number o droo , } Character of soil to a depth of 3 feet: �, _ ! Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to neatest: Well Foundation Property Line LEACHING UNE ❑ No. 8 Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest` Well Foundation Property Line F � SEEPAGE PITS Depth Number _ -"- - <' �= y SUMPS L] Distance to nearest: "�Well Foundation 0 Property Line DISPOSAL-PONDS ❑ r "�""'I'herehy certif y 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 applican st call f al re ired inspections. Complete drawing on reverse id ` Signed X Title: Date: g COR DEPARTMENT USE 06Q�/h+_ j ► ' a ' l D { Cr-�ra 1 .' ai YLrea m 13 Pdditional ion Accepted by e rout Inspection Date -7CZ Final Inspection by Date I Comments: ` - ❑ Stk 466-6781 11Lodi 369-3621 O Manteca 823-7104 ElTracy 835-(1385 Y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:-Haie`Itnri Ave., P.O. Box 2009, Stk., CA 95201 1 FEEMOUNT DUE AMOUNT REMITTER CK RECEIVED By DATE PERMIT NO. CASH t +.EH 13-24(REV.I/n sl IN I� ~ D EH 14-26