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r, r s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �rl..l�,�� 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. ' — 3 1 ' Job Address ¢ City Lot Size PM �IW0 1 In w s�, • wck ul,,pp d!. f r Owner's Name Address [ one Contractor Address Lk License No.�_IM Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT V DESTRUCTION ❑ ,.a4u5i! l!t PUMP INSTALLATION!lB/ SYSTEM REPAIR CI OTHER DISTANCE TO NEAREST: SEPTIC TANK R a` I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS __ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS y r © Industrial 00pen Bottom ❑ Manteca Dia. of Well Excaavattiion,,� Dia. of Well Casing 10 Lt 6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications�}., F7 Public n Other Cl Delta Depth of Grout Seal T� yppe,of Grout`1 SFICX M I X I I Irrigation _.-Approx. Depth I ('.Eastern Surface Seal Installed by� Repair Work Done ❑ Type of Punlp H.P. L State Work Done Well Destruction ❑ Well Diameter t Sealing Material (top 50') i Depth Filler Material ISelow,50'IY TYPE OF SEPTIC WORK•:---NEW-INSTALLATION-1-;,• REPAIR-ADDITION=.(-1--EiESTRUCTION•1-1 INo septic system permitted if public sewer is y 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: + j Water table depth v SEPTIC TANK ❑ "Type/Mfg Capacity 'No. Compartments r PKG. TREATMENT PLT. ❑ n t r Method of Disposal i Distance to nearest: ,Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: t:Well Foundation " Property Line h SEEPAGE PITS I 1 Depth Size Number SUMPS ❑. Distance to nearest: ' Well Foundation Property Line DISPOSAL-PONDS ❑-. } _-... _._� ._. �. __. I hereby certify that I have prepared this application and that the work wiil•be�done,in accordant d frith;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 Calif r The appiican all r all required inspections. Complete drawing on v r side. / p Signed X i Title: Date: !�Z7 6p f ' FOR DEPARTMENT USE ONLY Application Accepted by Date I t,7 Area Pit or Gout Inspection by Date Final inspection by Date Additional Comments: Ittt ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r I I INFO � AMOUNT DUE AMOUNT REMITTED DASH RECEIVED BY o L•-DATE PERMIT'NO. FEE'♦ EH 13-241REV.�/n5) �^ 1 EH 14-28 V 1