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i APPLICATION FOR PERMIT 'S` ! 1 SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Now Dvey � , Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED S,U (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 de cubed.This application'is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address 3 �� ' " �j �rJ �� City��0 Lot Size 9� 1240 6 PM Y)wner's Na a Address © r FrL bt�r Phone !\Contractor Address License No. Phone'If G I� TYPE OF WELL/PUMP: NEW WELL ❑ W L REPLAC ENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ YSTE REPAIR ❑ — OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE k FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS I_ ❑ Industrial LJOpen Bottom ElManteca Dia. of Well ccavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �A, t'i Public Ll Other CZ Delt Depth of Grout Seal Type of Grout—.—.—. I I Irrigation —.Approx. Depth l I tern Surface Seal Installed by- H.P. yH_p, State Work Done I Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 18elow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if 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 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 I 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 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 Di§trict. Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not C 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 taws of California." The appli t must c I for all required inspections. C mplete drawing on reverse side. f Signe Title: Date: R DEPARTMENT USE ONLY l App nation Accepted byO Date w Area I\ r Pit or Grout Inspection by Date Final Inspection by Date _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �y //CrAS�Hqrv- �Jy +.EH13-24MEV.i/FSS) EH 14.26 v