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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j r� {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 app Gcation is made in compliance with San Joaquin county Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address P City Lot Size PM Address Phone Owner's Name � j C Contractor Address7_ r_��e �vu�— Picense No. y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER F]DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Womestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout - I i Irrigation .. _..Approx.{Depth I i Eastern /Surface Seal Installed by k: )' H,p State Work Done Repair Work done � Type of Pump �� .� Well Destruction Ll well Diameter Sealing Material (top 50') Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (No septi cystithin m pefrmiitted if public sewer is availabInstallation will serve: Residence—1 Commercial— Other' Number of living units: Numbe!!!!r of bedrooms ; Character of soil to a depth of 3 feet:'I Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 4J j Method o� 1 Property Line ✓ Distance to'nearest: Well Foundation - Y 1 LEACHING LINE ❑ No. & Length of lines Total length/sizeV 19 -47 FILTER BED ❑ Distance to nearest: Well Foundation property Line�Y I i SEEPAGE PITS I I Depth Size Numher HEALTH i SUMPS Ll Distance to nearest: Wel! Foundation property Line pElZ�jT ERVICFc DISPOSAL PONDS ❑ l 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: "I certify that in the performance of the work for which this permit is issued, I shall not to workman's compensation employ any person laws of California." Contractor's hiring or sub-contracting signature in such manner as to become subject P 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 must II for al a red inspections. Complete drawing on r arse side. Signe Title: Date: L X�" • R DEPARTMENT USE ONLY Accepted b Date � � � Area Application p y Pit or Grout Inspection by bate Final Inspection by Date -a** Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environ}mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'ND. INFO 2 , tiGASH +` r.EH 1324 1REV. 00 C, �-1 r r 1 I ! EH 14-26 FI .