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- APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c - % ,. (Complete in Triplicate) , , ,. „, . r+iE�►,. 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, NO ,,' ��' .,, ty ms's /�Q X /�” P' ` 8C Lot Size - - ''- PM Job Address �n Q Ci Owner's Name _ ' — Address t l - Phone Contractor's Name C License No. -' �'� Phone; TYPE OF WELLIPUMP: ► NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. .. _ PROP. LINE FOUNDATION I AGRICULTURE WELL �OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ .Open Bottom E Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout } ❑ Irrigation —_JApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump'I H.P. State Work Dane Well Destruction ❑ Well Diameter.'}1 Sealing Material atop 501} r n Depth I 1 :` Filler Material {Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION o— DESTRUCTION ❑ (No septic system permitted if public sewer is -'- - - ' - "available withi 2 feet.) Installation will serve: -Residence Commercial= .Other Number of living units: Number,of bedrooms Zr Character of soil to a depth of 3;feet: F.! Water table depth 1 r' `r. Capacity , .. No. Compartments 1 n SEPTIC TANK ❑ Type/Mfg - PKG. TREATMENT PLT. F-1 �2 Method of Disposa{ _ A, • r Distance to nearest: 'Well. '� Foundation t Property Line LEACHING LINE [!T—No. & Length of lines Total,length/size FILTER BED ❑ Distanc_e to nearest: Well Foundation 7/d Property Line" v SEEPAGE PITS B—,Depth" 1 "SizeaTNuMber l SUMPS 11 Distance toii'nearest: £Well Foundation ',>/O ' Property Line U DISPOSAL PONDS ❑ 1 1 I hereby certify that 1 have prepared this application and that the work will bb-done in accordance with San Joaquin,county ordinances, state.Iaws, and rules and regulations of the San Joaquin Local Health District. a" " 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 applicant m call r all uired inspections. Complete drawing ort reverse side. z : Title: "^ Date: . Signed % y 3, r " F A T�USE ONLY Date Aa Application Accepted by { G Pit or Grout Inspe y Date _o Final Inspection by Date 4� Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ` ❑ Tracy 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE F AMIOUNT'REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO I b� ''! + EH 13-28[REV.10163) Li—_7 7 SH 1426 �` C> Z)