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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA f Telephone (209)466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED i (Complete in Triplicate) : Application is hereby made to the San Uoaquin 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. t t Job Address ' City, � dl� Lot Size PM a,owner's Name "' AcoFess —.._ a e Phone I l Contractor Addresslicense No.��Phone � f l 7 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. r� FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO ICATIONS} ❑ Industrial ❑ Open Botta"m ❑ Manteca Di ell Excavation - Dia. of Well Casing r ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � p 9 S ecifications F] Public F Other to Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I ] Eastern Surface Seal Installed by j Repair Work Done ElType of Pump H.P. State Work Done l a — r Well Destruction ❑ Well Diameter] Sealing Material (top 501 a Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK:- NEW INSTALLATION F I REPAIR/ADDITION l l DESTRUCTION (No septic system permitted if public sewer is i available within 200 feet.] l UInstallation will serve:Residence_ Commercial Other t a# q Number of living units:', Number of bedrooms r i Character,of-roil to a depth of 3 feet:]b — Water table depth SEPTIC TANK '" ❑ ^Type/Mfg Capacity No. Compartments -PKG. TREATMENT PLT. p Method of Disposal Nom" _ Distance'to nearest: Well ) Foundation Property Line i LEACHING LINE ❑ No. & Len'g'th of lines _ ._,« 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth l 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 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: "1 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." t The applicant m t call for all requi ed -nspecti ns. Complete drawing on reverse side. Signed Title: i Date: FOR DEPARTMENT USE ONLY Application Accepted by Aug Date l Area ! LJ ` Pit or Grout Inspection by `� Date V ` Finallns action by Date Additional Comments: f Q 07 Q ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&V5 �_.�g 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 DATE PERMIT'NO. INFO H ♦ EH 13-21 tr1EV,i ir<5lL ' EH 14-26 47 /