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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 TYEAR FROM DATE'`ISSUED t (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 bf the San Joaquin Local Health District. s Job Address '0_71 'r / !y City Lot Size PM Owner's Name AddressA phone ? Contractor 04Add ress s ' icense Nv. Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INST-ALi:ATION--E--•--^•^^------ —SY TEM-REPAIR-p. — -w=--OTHER-[] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C S RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. Well Excavation Dia. of Well Casing ❑ Domestic/Private �© Gravel Pack ❑ Tracy Type f Casing Specifications r f'l Public Cl Other C� Delta Dept of Grout Seal _ " Type of Grout I 1 Irrigation c "..Approx. Depth I I Eastern Surface Seal Installed by � 4 Repair Work Done ❑ Type of Pump ' H.P. ` State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 541 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I r DESTRUCT/PN I I lNo septic system permitted if public sewer is p` f availa %withiJ200 feet.) N Installation will serve: Residence_ Commercial_ Other Z" ' Number of living units: Number of bedrooms j/ Character of sol) to a depth of 3 feet: Water table`depih lll...(((111��Z SEPTIC TANK ❑ Type/Mfg Capacity Nq_jCompartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .Property Line LEACHING LINE ❑ No. & Length of tines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number r SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 r a 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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workirrlan's compensa- tion laws of California." i The applica t must call f "quiredlpections. Complete o ving on reverse side. Signed X Title: r Date: .F DEPARTMENT USE ONLY S} 1 Application Accepted by Date — Area �Z- <. u I � Jl Pit or Grout Inspection by t Date Final Inspection by ` Date ; i I Additional Comments: ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 635=6M5 "e y Applicant - Return all copies to: Erivir`6nmental Health Permit Srrvices 1601 E. Hazelton Ave., P.O B_ox:2009,-Stk.,C#95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY �. " DATE PERMIT-NO. +.EH13-241REV.iix5; EH 14-28 �.'[ ' �=V\�� `\.J•�.- I"'4 QO 1 f I: T