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e'er APPLICATION FOR PERMIT P AY M EN SAN JOAQUIN LOCAL HEALTH DISTRICT R ECE i V ED �. 1601 E. HAZEL I ON AVE., STOCKTON, CA 19$ 0 U yy� Telephone (209) 466-6781 �'�Q� PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED ENVIgQNMENT k HEALTH (Complete in Triplicate) pM17I5ERVkCES 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 Ryles and Regulations of the San Joaquin Local Health District. "{` t �> Job Address ' 1 ` T 421c),r 1 CI .�� J , tY Lot Size PM Owner's Name A Address ! Phdne Contractor Ad,dress h License No. Phone g7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL: OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca t,DofeI Dia. Well, ' - -, , , .,W� t. Dia. of Well Casing Domestic/Private ElGravel Pack ❑'Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal 4 Type of Grout ❑ Irrigation ___J4pprox. D Depth ❑ Eastern Sud—ace Seal Installed by Repair Work Dane Type of Pump H.P, State Work Done V Wel �l Destruction ❑ Well Diameter Sealing Material (top 50') i R �'",-\i Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: =NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence,ia Commercial Other I Number of living knits: Number of bedroorils of 3 fee Character of soil to a depth t:! Water table depth SEPTIC TANK ❑t Type/Mfg s r' j , � Capacity No. Compartments PKG. TREATMENT PLT, ❑ `– "" I Method of Disposal 00 Distance to nearest:fell Foundation Property Line LEACHING-LINE-- �- ❑—No._&-Ler)glb_of lines - -- Total IengtFa/size - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS E3 Depth –�;^-' Site Number SUMPS ❑ Distance to nearest: Well Foundation 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 y rules and regulations of the San Joaquin Local Health District. r 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,persori°in such manner'as.fo become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the•following:"I certify that it 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 m ca for all required"i ions plate drawing on re A side. k Signed Title: " Date: } –0 DEPARTMENT"USE�ONLY-----,- Application Accepted by - r ✓'� Date Area Pit or Grout Inspecti t Date Final Ins I ection by Date2' � �T Add'Rional Comments: ,. ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 ❑ Tracy 835 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 RECEIVED BY INFO DATE PERMIT' + EH13-24(REV.1/8 5) ' EH 14-26