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T r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. i f,r .I J TA 'X i.2 r . Job Address S City �►�° Lot Size �S 4 PM ''77032.0 Phone -,1 ?-$- 3 a ` Owner's Name ,�7 nab° ��" ��1e� Address I r 4`•0 � T { Contractor P� i "�- Address I � tf> • License No. Phone �— TYPE OF WELL/PUMP: NEW WELL ❑_. �WELL.REPLACEMENT E l_. r _DESTRUCTION.❑ PUMP INSTALLATION ❑ ` SYSTEM REPAIR ❑ `r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial 17Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing G� ❑ Domestic/Private ❑ Gravel Pack p.Tracy Type of Casing I Specifications \ 'j i e V FI Public � ! ❑ Other _�fl Delta Depth of Grout Seal Type of Grout - 'l I Irrigation` ---Approx. Depth' IJ Eastern Surface Seal Installed'by - Repair Work Done ❑ Type of Pump ` � H.P. � � State Work Done �- Well Destruction'. ❑ Well Diameter Sealing Material Itop 50'-' _ Depth Filler Material Melow,50'1 I .TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feel I Installation will serve: Residence_ Commercial— Other, Number of living units: i .P Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 'SEPTIC TANK ,r " ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT, ❑ . f Method of Disposal #� c,n', r I Distance to nearest: Well Foundation Property Line #LEACHING LINE ❑ No. & Length ofdines) Total length/size { FILTER BED E] Distance to.nearest;- Well Foundation '- Property Line a I SEEPAGE PITS 1-1 Depth -Size Number T SUMPS Ll Distance to nearest: Well Foundation{ Property Line DISPOSAL PONDS ❑ k Thereby 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. } I 'Home owner or licensed agent's signature certifies the following:�'I`certify that in the performance of the w`o'rk 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,1 shall employ persons subject to workman's compensa- tion laws of California.'yT� l The applicant must call for all required in ctions. Complete drawing on verse side. y Signed XTitle' 2(/ a�"zd Date: Y A FOR DEPARTMENT USE ONLY 4,/�6 Application Accepted by -,DateAreaPit or Grout Inspection by •`DateF'rnal Inspection by ' Dwe#f4� �. �,� jam, Addltlonal 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, Silk., CA 45201 i FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DAT PERMIT'NO. INFO �[,� Q� p hn + EH 13-24(REV.1 i H 5) �`" S 3"x,-71 / D � �� EH 14-2a