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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. .=:(Complete in Triplicate) j' 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 pr No..1862 for well/pump and the Rules and Regulations of the Sari Joaquin Local Health District. a 37 3 �.r j'w3 JIB} i ' Job'Address � City Lot Size PM, i Owner's Name(/ Address 79/� , t .n. Phone. �//J}n x - _ }��/ Contract Address rt�r ' t, -mac License No. =Q6. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'-0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approxl Depth ❑ Eastern Surface Seal Installed-by'° "„"I Repair Work Done ❑ Type of Pump H.P., ' State Work^Done Well Destruction ❑ Well Diameter Sealing'Material (top 50') f, Depth I Filler-MaterW (Belo 50') yrs' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /AbD1TION2r DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) F Installation will serve: Residence I Commercial='.Other r -•�---^--; r t i a 3 b Number of living units: � Number of a rooms i r r � Character of sail to a depth of 3 feet:i -Water table depth SEPTIC TANK ❑ Type/Mfg /% l Capacity No. Compartments PKG. TREATMENT PLT ❑ y Method of Disposal istance to nearest: Well fr Foundation Property Line LEACHING LINE " 7�, pR No..&.Lengthof lines Total length/size f FILTER BED-=r�" !''-O.1"Dis arice to nearest: Well Foundation - Property Line 4 r v SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well j�ro`= Foundation /ll r Property Line S7 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. j 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." i The applican must call all required inspections. Complete drawing on reverses e. i r f Signed X Title: 'C f T Date: r # FOR DEP RTM�ENT USE ONLY r FApplcation-Accepted by._ --- a - Date Area' v ' I `&Pi Grout Inspection by ^ate J f inal.Insp ction.by A7^_ Datg Additional Comments: ' ❑ 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 FEE INFO AMOUNT DUE_ AMOUNT REMITTED CK V CASH RECEIVED By DATE PERMIT'NO. •+ EH 13-21(REV.1/85) EH 1429 •_ ! 0` �� 3 �� L��j I O I � -