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Sc APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT ,f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r _ _ PERMIT EXPIRES 1YEAR FROM DATE ISSUED I r (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 Sim,Jou4in 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 Address CityA-1614VI-ot Size PM Owner's Name Address VI Phone 1 r Contractor �/ 1dressLicense No. 36 Phone ,,. TYPE OF WELL/PUMP: _ NEW WELL ❑ N, WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1,171"ra ' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f.'1 Public MOther ; Cl Delta Depth of Grout Seal Type of Grout _ * I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by W'Repair Work Done ❑ Type of Pump: H.P. State Work Done "r Well Destruction.. ❑ Well Diameter Sealing Material )top 50'1 ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I Y DESTRUCTION I I (No septic system permitted if public sewer i available within 200 feet.) 46stallation will serve: Residence— Commercial_ Other J,* Number of living units: Number of bedrooms N Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [W Type/Mfg Capacit No. Compartments r PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 2o orTotal length/size FILTER BED ElDistance to nearest: Well Foundation PropertySLine 4 _ 3, SEEP AGE PITS F I Depth Size _ Number +1 SUMPS ;; ❑ Distance to nearest: Well Foundation R Property Line { DISPOSAL PONDS ❑ f 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 .I rules and regulations of the San Joaquin Local Health District: ; i -Home owne�';or licensed agent's signature certifi s the following: "I certify that in the performance of therwork for which this permit is issued, I shall not employ any person in such manner as to b o subject to workman's compensation laws of California."-Contractor's hiring or sub-contracting signature certifies the followin certify that in ormance of the work for which this permit is issued,# I shall�ploy persons subject to workman's compensa- tion laws-of Calif, The applca " ' st a in cti Complete drawing on reverse side. - ti Signed Title: �/L '- ,. Date: FOR DEPARTMENT USE ONLY s Application Accepted by Date Area Pit or Grout Inspection by . Date Final Inspection6y - Date Additional Comments: I ❑ Stk" 466-6781 ❑ Lodi W91621 ❑ Pffanteca 823-7104 E&racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave.,.P.O. Box 2009; Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO r EHt4-28 3-24(REV.tins) EH 1 . ��/ �j�b� ..! --7 !t/