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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA REG Xv ED Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t,.Tjvv'� t F.. t , , (Complete in Triplicate) �NSALHEA1-� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here � t�tfoA is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and eguI4 San Joaquin Local Health District. Jab Address -7City Lot Size pM 237 'Qfo Owner's Name Address Phone f Contractor Address_cJAR15r42 License No. Phone TYPE OF WELL/PUMP: PQEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PUMP-INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ C DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE Vp FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a . ❑+IrJ¢ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing p Domestic/Private ❑ Gravel Pack (106-a—cy Type of Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installatr ' -serve: Residence_ Commercial Other Number of living urn Number of bedrooms Character of soil to a depth of Sleet;: Water table depth SEPTIC TANK ❑ Type/Mfg K Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method 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 C1 „} F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, laws, and I 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."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 call for all required inspections. Complete drawing on reverse side. ©© 7 v Signed Title: Date:J—'.2 S FOR DE ARTME T USE ONLY Application Accepted by Date 47 Area /U� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8:35-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9x201 FEE INFO AMOUNT DUE K H� AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO.' + EH1324(REV.1/85) � EH 14-28