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J + r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 District. rte' Job Address City �:� � � ✓� �` � �-�� f oil Owner's Name Address Phone Contractor's Name icense No. Pho E TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION �" SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC TANK /"Z4C_SEWER LINES DISPOSAL FLD. PROP. LINE oZ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑� Industria en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �} rL4�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �) E n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout li [IIrrigation Approx. Depth Eastern Surface Seal Installed by Repair Work Done LlType of Pum H.P. State Work Done 1n { Well ❑ _ Well Diameter Sealing Material (top 50'1 U r k D Wll Destruction Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other I Number�'of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth x 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 ❑ Depth Size Numberr SUMPS + ❑ Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ 1 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, Is hall 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." Theapplicant must it for al quired inspections. Complete a g on reverse side. f Signed Title: Date: 3- I FOR DEPA MENET USE ONLY i Application Accepted by Date" Area Pit or Grout Inspection by ate Final Inspection by Date 7 Z� Ad;itional Comments: f } ij�[Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104- ❑ Tracy 835 6385 App icant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton"Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIY'NO." INFO x. + EH 14-28(aEv.10/83) ir 1*-!S X41-7 '�t?/ 9-11 _!a1 EH 1428 �� , r: