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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 t. a (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. y 10 _ Job Addres 7 6 /S- ^W �a,G f - City Lot Size � 4-� PM Owner's Name �. l +, Address f�• '`<�• Phone Cont act / IPO uC` ate`C� Address If Lei 1 License No.��& Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i- ' PUMP INSTALLATION 1-1SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE P FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private [❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation —IApprox. Depth ❑ Eastern Surface Seal Installed by i � Repair Work Done El Types of Pump H:P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is .t i available within 200 feet.) Installation wilt serve: Residence Commercial— Other Number of living units: Number=droom � r IF 1: A 0 Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK 0;. Type/Mfg 4 r Capacity No. Compartments PKG. TREATMENT PLT. 0. `y ( Method of Disposal Distance to nearest: JVWell Foundation Property Line " LEACHING LINE No. & Length of;lines_-- " d Total length/size 'Ya r / FILTER BED ❑ Distance to nearest: Well'-.-'S-,0— Foundation 10 Property Line jSEEPAGE PITS Z depth Size Number SUMPS .❑ Distance to nearest: Well /C7 CJS. . Foundation—AQ-- Property Line I DISPOSAL PONDS © ,�• -- . - - �^ I hereby certify that I have prepared this application and that the work w1I 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-iii 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 mu call for all e' uir «inspections. Complete drawing11 on'reverse e. ' Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: 5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies"to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ( CASH e a EH 13-24 IRM 1/ 5) / 6!?i :'V 97—,;2EH 14-28 D