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e APPLICATION-FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT ► �`� �e P°` 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRESs1 YEAR FROM DATE ISSUED .. (Complete in Triplicate) b ' 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: r I Job Address City Lot Size w PM a Owner's Name !"` • Ir004E 8 Address '_J Phone Contractor Address re3 YX to License No Phone — a2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 01 PUMP INSTALLATION ❑ SYSTEM AEPAIR OTHER ❑Ir DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, 1 / 'DISPOSAL FLD. PROP. LINE i FOUNDATION• AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �• ❑ Industrial D,Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specificat�fis ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type',of Grout ❑ Irrigation —Approx. Depth ❑ Eastern r Sr ace Seal Installed by Repair Work Done Type of Pump ta H.P. State Work Done l! I + Well Destruction ❑ Well Diameter _ Sealing �--.-- .,.,_. _ _ � �_�-.....,�,.. - -•i i Depth' �'� Filler Material (Below-501 I' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑�DESTRUCTIOWLJ❑''{No septic sy'.stem permitted-if public sewer is '`available within 200 feet./_; Installation will serve:—Residence /-Commercial_ Other' L Number of living units: Number ofbedrooms .} Character of soil to a d4ptfirof 3Sfet:, 'a Water table depth It SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method Method of Disposal ` Distance to n`a est:,�..;�»Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size—i' FILTER BED ❑ Distance to nearest: Well Foundation Property Line 's SEEPAGE PITS ❑ Depth Size Number ' i SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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 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 manner 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 steali employ persons subject to workman's compensa- tion laws of California." i The applicantcall for all requ' Hsps ons. Co plate drawing on reverse side. �--- Z Signed X Ti Signed S _ Dater 7 FOR DEPARTMENT USE ONLY r Application Accepted by Date Z I Area ` � ✓ Pit or Grout Inspection b bate Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑.Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.;•P.O.-Box-2009,-Stk;CA-95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED)BY DATE j t I'ERI411T NO + EH 13-24IREV.i/asi �� e.�� EH 14-28