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i APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (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. I {- Job Address ,�r� y n City •J Size PM Owner's Name Address ' —' Phone Contractor's Name�-� �ti T �"•L"icense TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION {I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE —FOUNDATIO.N_ AGRICULTU RE WELL_ ,OTHER WELL PITS/SUM P$~—� — r FY �INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack EDTracy Type of Casing-^^ = Specifications Ll Public El Other--.. ❑ Delta Depth of Grout Seal Type of Grout N .r P ❑ Irrigation, { ---Approx i Depth LI Eastern Surface Seal Installed by � Repair Work Done Elp Type of Pum ' ,w, H.P. State Work Done well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION M--DESTRUCTION ❑,iNo septic system permitted if public sewer is ! available within 200 feet.) I t r fl{` Installation will serve: Residence-Inff-Eommercial^ Other Number of living units: Number of bedrooms 1p�l ¢ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK" ❑ Type/Mfg 4 Capacity No. Compartments ? PKG. TREATMENT PLT. ❑ f v Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE E�—No. & Length of lines Total length/size y0 I s FILTER B9D ❑ Distance to nearest: Well Foundation Prope y Line € SEEPAGE PITS r�%uepth 1-17 Size y 47 Number SUMPS W_--Distance to nearest: Well �~ Foundation Property Line r DISPOSAL PONDS ❑� F !�'� 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 perfor`mance;of the work for which this permit is issued, I shall not employ any person in suc manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ' ccff��rtifies the following:: ce -that in.the performance of.the work for which this permit is issued;I shall employ persons subject to workman's compensa titin. of alifornia." i ' The applicant m all for all r q ed i s c ns o late drawing on r erse side. ` s Signe Title:— — Date: FOR DEPARTMENT USE ONLY"- i } f r a Application Accepted by Date e l� 1 s Pit or Grout Inspection by Date, -Final Inspection by_ Vate k Additional Comments: f ❑ Stk 466-6781 13 Lodi .369-3621, F-1Manteca823-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services-1601 E. Hazelton Ave7P:0:'Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.10/831 4A EH 14-28 —--