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' APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT mks J 1601 E. HAZELTON AVE., STOCKTON, CA T 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 Jo�qu r n_&rdii ?nce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �• Job Address e Size � pM Owner's Nam +'Address Flo Contractors dres License dNor hon . TYPE OF WELL/PUMP: , NEW WELL - WELL REPLACEMENT ❑ DESTRUCTION_❑_ PUMP INSTALLATION _ -` SYSTEM REPAIR ❑ .. ._ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE z2 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 1nd� i I ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio fj Dia. of Well Casing arrest,/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications P Public ❑ Other F1 Delta Depth of Grout Seal I I Irrigation —Approx. Depth I 1 stern S rface Seal Installed by e of Grout— h Repair Work Done ❑ Type of Pump -H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 50') y Depth Filler Material (Below 50') �1 TYQL OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I.(No septic system permitted if public sewer is Installation will serve: ence� Commercial_ Other available within 200 feet.) Number of living units: u f bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. (11 Method of Disposal Distance to nearest: Well Foundatro Property Line LEACHING LINE C No. & Length of lines Total lengt FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size Number SUMPS L1 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 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 California." The applicant m call far all required inspections.-Cpmplete drawing on reverse side. Signed X Title: Date; �Q F R DEPA TMENT USE ONLY Application Accepted by / /Q-� -7 /�I� Date f Area / Pit or rout spection by Date 0 f� a Final Inspection by /' 6 _ Date � r� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 r FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMtT"NO. + EH 13-24 IAEV.r i n 51 /� EH 14-26 /!/ S a ��rt