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l 1`� ' d w ZCp APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. r �j Job Address Lot Size PM Owner's Name Address Phone 946— Contractor fContractor Address License No. Phone TNLOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: < SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONCULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati �DiaWell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ations ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by o Repair Work Done ❑ Type of Pump H.P. State Work Done \\v Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 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� Comm W101e P"PIRED Number of living units: � Number of be oa sLA Character of soil to a depth of 3 feet: .5Water table depth SEPTIC TANK ❑ Type/Mfg " "�jriA With No. Compartments PKG. TREATMENT PLT. ❑ N�� Method of Disposal work' being W �g j Or inspecWg m� Distance to nearest: Well a Line bV Fnvironrnc.�-,tol Health Division LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation' :Property Line DISPOSAL PONDS ❑ 1 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 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: "t 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 app:-:-n::t' amys call for alv, in ctions Complete drawing on reverse side. Signed `d��_ ./t � _ .Title: �wu Date: FOR DEPARTMENT USE ONLY Application Accepted byDate 7-3 L) Area Qg?2- . °� het . eP �;, !� 1 — Pit or Grout Inspection by ate mal nspec ron�b��,J __ r Date Additional Comments: --�►^ C' ""rte V �a4z1� C1 Stk 466-6781 E3Lodi -3621 C3 Manteca 623-7104 El Tracy 835-6385 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 RECEIVED BY DATE PERMIT N0. INFO T5 �.�r ��lJ1, + EH 14-26IFEV.t/asl �C3 d �'I♦� [ ZJ