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_ APPLICATION FOWPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address Cf ' CL ] V City-5—Il Lot Size PM Name ame Address ��.� .. Phone �• Le W -T HH V4L l License No. Ll -[ c� } Contractor's Name Phone _TYPE.OF_WELL/PUMP: _NEW WELL ❑ __. _. -WELL REPLACEMENT,.EJ,_. -DESTRUCTION.-C.- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing i ❑ Domestic/Private IDGravel Pack ElTracy Type of Casing—t. Specifications } LlPublic 1 ❑ Other _ ❑_Delta Depth of Grout Seal r o , � ...-.._ p - Type of Grout ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by -- Repair'Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') e Depth r Filler Material (Below 50') , TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TRUCTION ❑ (No septic system permitted if public sewer is / available within 200 feet.) f Installation will serve: Residence A—� Commercial I— 'Other O -Number of living units:--IL Number of bedrooms Character of soil to a depth of 3 feet: 1)[Z[�� Water table depth SEPTIC TANK 19.1Type/Mfg ( Capacity No. Compartments ) PKG.TREATMENT PLT. ❑ , Method of Disposal i (Distance to.nearest: Well l Foundation Property Line j i LEACHING LINE D-- N,-&,L-ength--of�lines b Total length/size- - FILTER ength/size "FILTER Bi D ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS a -6epth __ 5ize 3 Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaiquin 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 itheperformance of the work for which this permit is issued, I shall not employ a 6 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- n law's'of California." The appiic ust call for Il required i spectio s. Completedrawing/orr reverse si y� Title. ` Date: LFOR DEPARTMENT USE ON€Y Application Accepted by Date 4� Pit or Graut Inspection by Date Final Inspection by__ y- - - - Date i Additional Comments: { ❑ Stk 466-6781 ❑ Lodi 369-3621 El-Manteca 634104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE} INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT"NO. -} * ! �+EH 13.24(REVH 14 . t -k/0/S31 0-0 �� .1� � - +o L --)-r\ -/- 0 I (� I-