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Ag eA APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT .' is i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 1 PERMIT EXPIRES 1..YEAR-FROM DATE ISSUED , {Complete in:Triplicate}.3 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. Job Address ;9/" City -Lot size is �� ,PM: xOwner's Name Address �/ �e� a� Phone Contractor I�. Address License No. Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q 'lN'TENDED USE' - TYPE OF WELLY PROBLEM AREA 'CONSTRUCT_ ION SPECIFICATIONS LJ Industrial _ ❑ Open Bottom ❑ Manteca Dia:of Well Excavation .era Dia. of Well Casing El Domestic/Private ❑ Gra4el Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigationpprox. Depth ❑ Eastern Surface Seal Installed by , Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONNX INo septic system permitted if public sewer is -,available within 200 feet.) Installation will serve: Residence Commercial_ Other • `� t Number of living units: 'Number of bedrooms i Character of soil to a depth of 3-feet: ' Water table depth SEPTIC TANK �Type;Mfg Capacity Compartments ' PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line "I EACHING LINE ❑ No.,& Length of lines Total length/size i ' 9 14- A. FILTER .BED ❑ Distance to nearest: Well Foundation Property Line I � � IJ SEEPAGE PITS Depth oi5 Size Number SUMPS ❑ Distance to nearest: Well Foundation -Property Line DISPOSAL PONDS [I 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: "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." .f The applicant usst c-alI for all all 'equired iinnsspe/ct/ions. Complete drawing on reverse side. Signed XW-J� 7 cJ d I tLL.�r Title: Date: t p t_ . ,. 1 w_ ,FOR.DEPARTMENT USE ONLY, f Application Accepted by i 1 1 Date Area ' Pit or Grout Inspection Dae '} Fina Inspection by Date Additional Comments: fov R ❑ Stk 466-6781 ❑ Lodi 369-301 ❑ Manteca 823-7104 Cl Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED' C RECEIVED BY" DATE PERMIT'NO. �a1• INFO . + EH13-24(RM 1i85] EH 14-28