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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NJ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W0 / (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 far sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. r Job AddressQ 1 () City Lot Size PM Owner's Name Hr C45tJ& r fZ ! -/ Address 0 U Phone 7.bv � � P.-A- 1P tLC2.1 S!4 Contracto "' d��Address 9 1v C11.7( c e}I4 License No.A_25 I �Phone 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 F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (`Q 'D Domestic/Private '"' ❑ Gravel Pack ❑ Trac T e of Casin v - Y yp g Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 'Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surfacg Seal Installed by Repair Work Done ❑'� Type of Pump H.P. State Work Done Well Destruction ❑ 1 Well DiameterSealing Material ;fop 5011 Depth Filler Material (Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION SNo septic system permitted if public sewer is r/ vailable within.200 feet.) e Installation will serve: ' Residence' \ Commercial_ Other Number of living units: Number of bedrooms y Character of soil to a depof 3 feet: ( Water table depth SEPTIC TANKType/Mfg Capacity No. Compartments PKG. TREATMENT PLT., ❑ j Method of Disposal Distance to nearest: Well i _Foundation 4 Property Line F LEACHING LINE 4 ❑ No. & Length of lines 1' Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation j v Property Line SEEPAGE PITS ❑ Depth Size Number i S SUMPS ❑ Distance to nearest:_.-Well---Foundation 'poperty 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. 'r ` r t 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." Cantractqts 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 . s call for all r d ins ctions omplete drawing on reverse sicip. ? Signed Title: Date:7�� o� ' �FORP�AT.1Z,ENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection byDate Additional Comments: ❑I 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# RECEIVED BY DATE' PERMIT'N0. INFO CASH + EH 13-24 4REV.i/a 5) EH 14-26