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f Z_-.SS • APPLICATION FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE,, STOCKTON, CA Telephone (209) 466-6781 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. nn 8 Job Address U U f tst cltj w—St Lot Size--C scix PM Owner's Name dress Phone Contractor QJ" Address 3 Sb VV C–L i9L)Lt0_LL License No. d ;._ Phone S 5 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRCIFICATIONS f `t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing ations o- ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grou ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is available within 200 feet.l 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. ❑ - a Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines 1 Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation--.. Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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:"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 la of California." The a plican ust call for�requir&insctio s. Complete drawing o reverse si e. Signed X Title- Date. FO EPARTMENT USE ONLY Application Accepted by _ Date2�'� ;, Pit or Grout Inspection by Date Final Inspection by Date - 1 —i-7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-301 ❑ Manteca 823-7104 ❑ Tracy 5 63B5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 901 FEE INFO AMOUNT Dp�U/lELL AMOUNT REMITTED CK RECEIVED BY DATE PERM W NO. + EH 1&24IflE'V.rix5) r 00 / is �, Y� EH 14-25 G�'J tJ 00 O