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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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. ?, Job Address V ie J4 a City 0 Lot Size t`C3 ��-� PM Owner's Name !: Gl Address Phone If Contractor Lza l T . 3 Address 1License Na.QtQg3$3 phone �� •�7� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTAL-CATION.., ' -_.OTHER-0. r,, �.. SYSTEM. , _.DISTANCE TO NEAREST: .SEPTIC TANK �8 SEWER LINES DISPOSAL FLD.lSO 'PROP. LINE _. FOUNDATION r-J AGRICULTURE WELL j1,6-f— OTHER WELL CIG. t_ PITS/SUMPS IC INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 1 ❑ Industrial - XOpen Bottom ❑ Manteca Dia. of Well Excavation—. ) Dia. of Well Casing a -Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing�LC_�_! ..e Specifications FI Public _ 11 Other F Delta Depth of Grout Seal Type-of rout yvt to �� a I I Irrigation -� - fLv__-Approx.•Depth... I.1 Eastern Su ace Seal Installed by ` Repair Work Done ❑ Type of Pump � �— H.P, State Work pone Well Destruction .. ❑� Well Diameter - -- - Sealing-Material-(top 50'-) t �---- ��-�- - .Depth- Filler•Material-l'Below_W)._ TYPE OF SEPTIC WORK; NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: Water table depth1 SEPTIC TANK E] Type/Mfg Capacity Compartments No. Cam V PKG. TREATMENT PLT. ❑ Method of Disposal C } j Distance to nearest: Well Foundation --pro perty line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth' ` Size Number` + SUMPS Cl Distance to nearest: Well Foundation% Property brie DISPOSAL PONDS ❑ - - I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a rules and regulations of the San Joaquin Local Health District. I 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 applicant must call for all required inspections. Comzplete drawing on reverse side. Signed -. C Y -�". ".'�."'. Title' - -� Date• FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date 0 /Final Inspection l,y Date, 2 r Additional Comments:: ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-71046 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 'AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMITN0. +.EH 13-24(REV.i i H 5) EH 14-28