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`I I� APPLICATION FOR PERMIT `Y3 G f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA. ii Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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 of the San Joaquin Local Health Distr-ct. Job Address ��'`"' � ' � �� """' City � Lot Size PM Owner's Nam ```'` Address - dL' Phone Name Contractor �` Address C A, Q � License rrd� �-� Phone �`+ TYPE OF WELL/PUMP: NEW WELL ❑` '� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONt'?`_ SYSTEM REPAIR OTHER ❑ NK DISTANCE TO NEAREST: SEPTIC TAI LINES D POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS V\31 O'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing = r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f Type of Casing Specifications - M Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout 1 I Irrigation — - .�_';Approx. Depth I I Eastern I Surface Seal Installed by - Repair Work Done l" Type.of Pump H.P. State Work Done ~ 4 Well Destruction ❑ Well.Diameter Sealing aterial (top 50'1 i Depth' Filler M _rial Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLALION,11 REPAIRIAD ITION i I DESTRUCTION 1 1 INo 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 I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of Fines Total length/size FILTER BED ❑ Distance to nearest: Well 'i Foundation Property Line I SEEPAGE PITS I I Depth Size f � Number SUMPS L) Distance to nearest: Well `,Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the wo k will be done in accordance with San Joaquin county ordinances, state laws, andJ rules and regulations of the San Joaquin Local Health District. I. i 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, l shall nq 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',..,,,,t tion laws of California." # The applicant mAM call for all required inspections. Completes drawing-on reverse side. Signed X , Date: J, oF I FOR DEI ARTMENT USE ONLY i� s� Application Accepted by Q Date 1 A-2 `-� Area D d._. � Pit or Grout Inspection by Date � Final Inspection by Date I - t Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ 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 CASH +.EH 13-24(REV.t/H 5) V•-a--a ,�� 0 .EH 14-26 l7 :7