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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT a 1601 C, HAZILTON AVE,STOCKTON, CA � Telephone 42091 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. +, �— , �1 , ., Job Address * City Lot Size PM Owner's Name Address SPG !/�>�� Phone Contractor . Address License No- ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `I N`•..DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '' Dia. of Well Casing "�j ❑ Domestic/Private D Gravel Pack © Tracy: Type of Casing Specifications ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump{ H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 t 1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) r3 Installation will serve: Residence Commercial_ Other y rl ! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r; SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments 'PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l (a LEACHING LINE ❑ 'No'&,Length of lines Total length/size x, FILTER BED ❑ Distance to nearest: Well ' Foundation _ Property Linef SEEPAGE PITS ❑ Depth "d r� Size Number SUMPS ❑ Distance to nearest: ::Well t Foundation Property Line DISPOSAL PONDS ❑ I -r art. I hereby certify that I have prepared this application and that the work will-b6 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 applicanust call for all required inspections. complete drawing on reverse side. l t Signed X ! Title:� Date: { } FOR DEPARTMENT USE ONLY I Application Accepted by I Data Area r i r Pit or Grout Inspection by Date' Final Inspection by 11 Date / ~� Adotional-Comments.°`-""` ^`""""" �"�"� '>(Stk 466-6781 ❑ Lodi 369-3621 4'-*- ❑w Manteca 823-7104` ❑ Tracy: 8355-6385 E 'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Aazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE r AMOUNT REMITTED AS RECEIVED-BY DATE PERMIT'NO. D It INFO —7— + EN 13-244REV.1/1151 ' .3�. O J a Vp 3 ft, 01V~ L05 EH 14-26 .. ... _ v i