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.s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a �.? 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 t LPERMIT 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. " Job Address City Lot Size ' PM E Owner's Name Wo Address Phone f Contractor Address z5,36 ,� License Pho .0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "'`µ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac T b. Tracy Type of Casing - r' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 4 " Type of Grout ❑ Irrigation .--Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter' Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: 44 Water table depth SEPTIC TANKType/Mfg Capacity No. Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal 1 Distance to nearest: + Well Foundation Property Line 5 LEACHING LINE , ❑ No. & Length of lines Total length/size FILTER BED ` ❑ Distance.to�nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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."Contractors hiring or subcontracting 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." i The applicant mu call for all required - spec'ons. Complete drawing an reverse sid v v / Signed Title: ...._. Date: FOR DEPARTMENT USE ONLY sOn Application Accepted by Date '� L+ Area Pit or Grout Inspection b Date Final Inspection _ Date t Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354085i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE y�PA.�M/O�UUNT REMITTED �K H AV RECEIVED BY DATE PERMIT- INFO N0. {,SEH 1324[FL:V.t i e 5i -" PIS .28 EM 4 1 w