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APPLICATION FOR PERMIT Z SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE.,�STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPI4ES'1 YEAR FROM DATE ISSUED (Completein 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 C Local Health District. Job Address - !1 City Lot Sizer 7C/�� PM Owner's Name' Address QPhone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ yV DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing - i ❑Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation _-4pprox. 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 i Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is -flvailable within 200 feet.) Installation will serve: Residence Commercial_ Other { n Number of living units: Number of bedrooms i a Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK Ela Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ j { Method of Disposal ` Distance to,nearest: Well. Foundation r Property Line LEACHING LINE CI No. & Length.of lines. "t ' Total length/size FILTER BED ❑=Distance to nearest Well 4'> r= Foundation Property Line SEEPAGE PITS El" Depth Size v., -..,Number SUMPS Y, ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 thabin t- he 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 tiie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requ•red •inspect; ns. Complete drawing on reverse side. Signed X �JSTitley - Date: . . FOR DEPARTMENT USE ONLY Z-7 '4� a Application Accepted by Date nn Area Pit or Grout Inspection by Date Final Inspection by „�,c'N�� Date A ditional Comments: Stk 466 6761 ❑ Lodi 369-3621 ❑ Mantecax 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r `INFO__AMOUNT,,DUE-, e.-AMOUNT-.REMITTED - CK l RECEIVED'BY! DATE PE/RMIT•NO. a EH 13-24 iREV.i/ns) ®� U 37-.c5(� 3 _X--7—� Y(O lV4o EH 14-26 r i