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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. &YJob Address ity f of Size PM Owner's Name t� OF. Address' Phone i & 4 _— Contractor Address cY"— License No Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WE RE ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ j Y TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULT WELL OTHER WELL— ,INTENDED .INTENDED USE TYPE OF WELL PROBLEM ARE C NSTRUCTION SPECIFICATIONS [71Industrial ❑ Open Bottom 171 Mann 4a. of Well Excavation Dia. of Well Casing El Domestic/ ElGravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ r 1 1 Irrigation _.-Approx. Depth i I Easter Surface Seal Installed by _ Repair Work Done ,❑ Type of Pump H.P. State Work Done_ 6 Well Destruction © Well Diameter Sealing Material (top 501 S1 Depth Filler Materiah 18elow 501 l f► TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is "} available within 200 feet.) Installation will serve. Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/.Mfg 1. Capacity. No. Compartments PKG. TREATMENT PLT.❑ ! rA -IL Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines *it `Total length/size FILTER BED ❑ Distance to nearest: ,Well_f _J _ Foundation Property Line V 0 7' r0SEEPAGE PITS l 1 Depth Size Number �ff SUMPS Cl Distance to neares : Well 7� Foundation 0 Q Property Line T 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 Lthe 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 signage certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons.subjectto-workman's compensa- tion laws of California." `r \Ix 1 The applicanrp ust call for required ' spections. Complete drawing on reverse side. Signed X Title: ,e Date: ,Z z F R DEP RTMENT USE ONLY t p Application Accepted by Date p r��90 Area (Y 41�Pit or Grout Inspeciion by Date Final Inspection by �� DateU 41 Additional Comments: ❑ 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 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. t EH 1324(REV.r i K 5) `�, EH 14-28 `� a-O7