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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ED 1601 E. HAZEL i ON AVE., STOCKTON, CA �� Telephone 1209) 466-6781 P� � � 19g1 PERMIT EXPIRES #'YEAR FROM DATE IS O 9 1 � Mj� (Complete in Triplicate) 1A 41 . �� '� cE's g �7hts application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ Mations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewn a or No. 16&2 for well/pu N � > q11 Local Health District. �N1 Q City Lot Size PM Job Address [(c�,� Owner's Name siG Address ` Dy f Phone 3 ` oillttf ess ,0e %Lug' icense by Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ESTRUCTION i t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 cr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc Dia. of Well Casing ❑ Domestic IPrivate ❑ Gravel Pack ❑ Tracy o Casing Specifications p / Type of Grout C"] Public €� Other eta Depth - — I 1 1 Irrigation ax. Depth l I Eastern Surface Seal Installed by - Repair Work Done ype of Pump H.P. . State Work Done _ Well Destru Well Diameter Sealing Material atop 50'1 ` f Depth Filler !Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.i 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 l „- SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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 Di§trict. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applican ust II for all,r qu' d ' ctions. Complete drawing on reverse side. r (� 454 Q/ Signed X Title: / date: F. DEPARTMENT USE ONLY i Application Accepted by Date / r Area Pit or Grout Inspection by Date Final Inspection by r Date oil l i Additional Comments: O 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 F EE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 9 a.EH 13-24(REV.I/h b) 1 L ��134 EH 1428