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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I 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. F F Job Address I0/_ City Lot Size PM 1. Owner's Name �G Address Phone Contractor's Name UnWnse No. Phone aq TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom T❑ Manteca`"' _. 'Dia. of Well Excavation ► pia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 4 State Work Done Well Destruction E3 Well Diameter Sealing Material (top 50') 1J Depth Filler Material (Below 501 C I TYPE OF SEPTIC WORK: NEW INSTALLATION,❑ REPAIR/ADDITIO DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: ~Number ofedrooms Character of soil to a depth of 3 feet: 1 �' '` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ NMethod of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE No. &Length of lines Notal length/size FILTER BED ❑ Distance to nearest: WellI &I Foundation P U Property Line SEEPAGE PITS ❑ Depth --- Size Number SUMPS ❑ Distance to riea`resti Well Foundation Property Line- DISPOSAL PONDS ❑ 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. '* "f V 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- `n tiori'laws of California." The applican�st fo require ' spections. Complete drawing on r rse side.•r,,� Signed Title: Date: FOR EPARTMENT USE ONLY Application Accepted'by Date t Pit or Grout Inspection by.f Date T Final Inspection by a4f Date 1712 + l' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy F 835-15385 Applicant 1 Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ti FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE ''7�_ PERMIT/`NO. r I- +EH 1324(REV.101631 06 --- 1 _g3- !/"17q_6 I .'• EH 14.26 A l