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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. r Job Address r+ �r if R�d D sy% CityP Lot SizeIF PM 0* Owner's Name �C P Address `V �'V �� I'y Phone �� 5 Contractor Address 74 t License No9` Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI IC TANK SEWER LINESDISP FLD. PROP. LINE h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v INTENDED USE TYPE OF WELL PROBLEM AREA >". CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well fxcavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F]l Public ❑ Other ❑ D Depth of Grout Seal Type of Grout =- I I Irrigation Approx. Depth astern Surface Seal liistalled by Repair Work Done �❑ Type of Purnp H.P. State Work Done _ Well Destructions 0 Well Diameter ' Sealing Material (tap 50') Depth "r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR IADDITION l'I DESTRUCTIONlNo septic system permitted if public sewer is E available within 200 feet:l i Installation will serve: Residence_ Commercial_ Other Number-of living units: . Number-of bedroomsc -- + Water table depth + Characterof sail to a-depth of 3 feet: SEPTIC TANK ❑. Type/Mfg Capacity No. Compartments n Method of Disposal � PKG. TREATMENT PLT. ❑_ �.-- -' ,..�...,,.-...,....:_�..� __.,•- _-_.... .... . ,....,..._.: .. .---- -: Distance to nearest: Well Foundation t r Property.Line i LEACHING LINE 1 ❑'t No, Length'of lines T al length/sizeJL I i fILT,ER BED } ❑x Distance to nearest. :'"Welk Foundation- Property Line SEEPAGE.PITS j 11 Depth � ? Size Number -St3MPSr- I�L1—Ehstance 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 Dif;trict. 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 Califofnia.".Contractors hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued I shall employ poisons subject to workman's compensa tion laws of California," ` s+ t• _ The applicant mus call for all requir d "inspections. Complete drawing on reverse s'de. F i 1. Signed X Title: Date: y FOR DEPARTMENT USE ONLY Application Accepted by �'o( Date v a Area Pit or Grout Inspection by Date Final Inspection byf Date r Additional Comments: i Q�l dna Cl Stk 466-6781 ❑ Lodi 369-3621 Ca 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 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO . +.Eti 13-24(REV.r f n sl EH 1426 i