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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT V I 1601 E. HAZE.T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 i - 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. �j��y Job Address ! IrCJ. �1W! E �i�1>�� City Lot Size PM I Owner's Name _/tivI� � j Address IPfQ Phone I Contractor!� �J�� Address.aC+I�f1 ��-+C�� License No. W/ZSlll�'' Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ -OTHEfj ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,2� PROP. LINE FOUNDATION AGRICULTURE WELL r OTHER WELL' "F PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial- ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing bDomestic/Private .VGravel Pack ❑ Tracy Type of Casing 4Specifications M Public [7) Other , ';A Delta Depth of Grout Seal ��WVVYY Type of Grout IEf: I I Irrigation ` WApprox, Depth- I I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pum p$ _ H.P. �_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r_ e Depth Filler Material IBelow 50') �_ G TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is d available within 200 feet.) Installation will serve Residence} Commercial_ Other k Number of'living units: Number of bedrooms Character of sail to a depth of 3 feet: ) Water table depth I SEPTIC TANK ❑ Type/Mfg f 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 i FILTER BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _ Size _ Number SUMPS LI 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, an i 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 1 certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." _I The applican H t r II re ctions. Complete drawing on rever e-sida. ^ Signed X Title: -` Date: i15 i FOR DEPARTMENT USE ONLY ' Application Accepted by 1IA;( Date / /r Area , jZ�-G —� Pit or Grout Inspection 6y Data_f r Final Inspecti Date 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 9 CASH RECEIVED BY r- - DATE V PERMIT No, ? -'.+-EH-13-21(REV.i H 51 {0 S D 'oa EH 1I-2fl 1