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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. r I (77C Job Address —_/a! � Lrl� City J V Lot Size PM Owner's Name �� e s / /��` �A� one 9 Contractorz 7��ire_ AddressA3/,?m /�License No. � Phone TYPE OF WELL/PUMP: VIEW WELL 0 WELL REP''LACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Tracy Type of Casing Specifications f'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth er eriai (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1REPAIR/A ITION DESTRUCTION.') I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other �` � f T Number of living units: Number of bedrooms ra Character of soil to a depth of 3 feet: Water ta61e depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \a� PKG. TREATMENT PLT. ❑ Method of Disposal 1100 Distance to nearest: Well Foundation Property Line 9 LEACHING LINE o. & Length of lines """ To�tal length/size W FILTER BED ❑ Distance to nearest: Well �� Foundation Property Line A-60 SEEPAGE PITS ("Depth Size_ 3 Nu ber � SUMPS Ll Distance to nearest: Well 2_/ Foundation W61 Property Line O \ 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, I shall not employ any persLinsmanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follotify that in the performanceof the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of CaliThe applic t require ins ction p drawing o everse sid f ned X Title: Date: FOR PARTMENT ONLY Application Accepted by ;Date ` �\�� v 1 Area Pit or Grout Inspection by D6io Final Inspection by4 �.I L,_� Date k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/8 5) EH 14-28