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APPLICATION FOR PERMIT r d� SAN JOAQUIN LOCAL HEALTH DISTRICT f/1 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) :. 4 . 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 incompliance 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. dity gLo .lob Address Lot Siza PM Owner's Name Address —_ hone Contractor's Name License No. 'K"V Phone TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ..} SYSTEM REPAIR ❑ OTHER ❑ y. DISTANCE TO NEAREST: SEPTIC TANK -SEWER.LINES N} t " DISPOSAL.FLD. __PROP. LINE' '- FOUNDATION AGRICULTURE WELL ''f r OTHER WELL w PITS/SUMPS .. INTENDED USE TYPE OF WELL PROBLEM AREA, t CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing ❑ Domestic/Private -1P,0-Gravel Pack 's ❑ Tracy Type of Casing- Specifications. ❑ Public ❑ Other ❑,Deltas-N "" Depth of rout Seal Type of Grout I _ I ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P.- - '''State Work Done !s Well Destruction ❑ ,Well Diameter+ Sealing Material (top 50') Depth" w ' Filler Mate�ial-(13elow 59'). I TYPE OF SEPTIC WOR K:''NEW:INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ lNo septic system permitted if public sewer is' f available within 200 feet.)N. I Installation will serve: Res'. nfe Commercial_ Other • r i `"�' k Number of living units: 1 Nu er of bedrooms Y ? a d Character of soil to a de th of 3 feet: _ Water table depth F SEPTIC TANK ❑ Type/Mf PKG. TREATMENT PLT. ❑ Meth d of Disposalpis aOet,-no Well Foundation.." Properry`Line LEACHING LINE, No. & Length of lines = ' Total length/size r FILTER BED ❑ Distance to nearest: W Foundation _ Property Line SEEPAGE PITS Depth �` Size ��. t _ _ Number } SUMPS ❑ Distance to nearest: Well Foundatio,:' / Property` Line 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 " 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." The ap c for a uire,0,inspections. Complete drawing an reverse side: }y t Signed Title: _ �.— Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date .":�- 6 Additional'.Comments: - ❑ Stk 456.6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 0 Tracy 835.6385 Applicant- Return all copies'to: Environmen#al Health Permit/Services 1601'E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 Y. FEE i' INFO -AMOUNT DUE AMOUNT REMITTED CC t'nH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.10/83) Z5 EH 1426 �+I 1fl 133 s r