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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 � - 1 (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 Joe u'n ounty Ordinance No.549 for sewage or No.1862-for well/pump and the Rules and Regulations of the San Joaquin F Local Health District. a Job Address _ City /��G" Lot Size PM - t Owner's Name t� Address Phone }� / ,fit Contractor xf �. f !i/� Odress icense No.iQ? TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Manteca a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications !� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutM� El Irrigation --Approx. Depth-_ ""❑ EasteFrri ,""" Suiface Seal-Installed by 1�1 Repair Work Done ❑ Type-of Pump " r H.P. State Work Done Well Destruction ❑ Well DiameterF"rt t Sealing Material (top 50'1 Depth '-` `Filler Material (Below 501 v TYPE OF SEPTIC.-WORK:—NEW INSTAL-1:A710N ❑ REPAIR/ADDITION FDESTRUCTION ❑ (No septic system permitted if public sewer is < t available within 200 feet.) _,� Installation will serve* Residence , Commercial ,`Number of living units:—4— Number of bedrooms i Character of soil to a depth of 3 feet: A 0n & Water table depth ' SEPTIC TANK0,"Type/Mfg �� / "'� "�` "Capacity "" '" Na. Compartments r r Method of Disposal - PKG. TREATMENT PLT. ❑' s Distance to nearest:, Well Foundation Prbperty Line I LEACHING LINE No. & Length of�l es 7!i✓ __total length/size ZC0d T FILTER BED '„l .. ❑• Distance to nearest: well. ��Foundation Property Line r a I SEEPAGE PITS ❑- Depth I �3 Size X Nur Y. k SUMPS; �' i Distance to nearest: Welles Foundation Property Line Y I 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 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 fo II r quired inspec ions. Complete drawing on reverse side. /r i t Signed 1. Title:�.,,�� Date: a r k DEPARTMENT,USE ONLY t — A 44,1 / J� Aodk licatin"Acce teb a ' �- 1 / jJ PP p Y�•'. _ Date Area t - 'OF 'Pit or Grout Inspection by , L " Date Final Inspection by " Dati�z� r Additional Comments:, ' '❑ Stk 466=6781 ❑ Lodi 369-3621' `❑ Manteca $23-7104 ❑ Tracy 835�i85 Applicant- Return all copies to: Environmental Health PermVServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IN l # FEE AMDUNT DUE- AMOUNT REMITTEDr, CASK ,. RECEIVED BY DATE PER JO. INFO +EH 13-24 01111.1/85) EH 1428 G