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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROW 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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. At . J � 1 C G' t. L City — PM Job Address (� Owner's Name J_.�L��►h'�� Address� J S Q Phone 47LS 4 Contractorbie w. QS Address License No. Phone TYPE OF WELL/PUMP: NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION If SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E-1Industrial ❑ Open Bottom ❑ Manteca Dia. of We11 Excavation Dia. of Well Casing ❑ Doo estic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications C}'Public ❑ Other ❑ Delta �� Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Deptp ❑ EasternSurface Seal installed by' Repair-Work Done Type of Pump H..P. State Work Done Lel Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 y Depth Filler Material (Below 50') n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence— Commercial'_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity � No. Compartments PKG.-TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ DepthL Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 regulati6s o San Joaquin Local Health District. Home ownr licensed ag is si er ognature certifies the following: '.'I certify that in the performance of the work for which this permit is issued, I shall not employ aFy person in such nner as to become subject t rkman's pensation laws of California."Contractor's hiring or sub-contracting signature cerrifidthe following:"'I ce ify that in the rmanc the work r which this permit is issued,I shall employ persons subject to workman's compensa tion I ws of Califorrn ." ! i The pplica mus or all r uire i drawing on reve e. Signed Title: Date: ' FO EPARTMfNT USE ON'LY - r Application.Accepted-by- Date Area Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 C3 Manteca 623-7104 ❑ Tracy 8355-6385 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 CASH RECEIVED BY DATE PERMIT NO. I INFO Ju +EH 13-24 VIEV.1/8 5) C { �2 V EH 14-28 J }