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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA. ' Telephone {209) 466-6781 L I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) e-N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work�h f r' Thi catio made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a rd� e San Joaquin Local Health District. Job Address }�� ®,S PRC,��' City Lot Size Owner's Name Address /2-59i2l �� phone Contractor's Name License No. 1P _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.Er OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,.P'bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public EI Other 1-1DeltaDepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �+ Repair Work Done ❑ Type of Pump �\,.& — H.P._r�" # St a Work Done ' Well Destruction 13 Well Diameter Sealing Material (top 50'.1 N Depth Filler Material [Below 50'} ' TYPE OF SEPTIC WORK: NEW INSTALLATtON'O 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I" - ' � t available within 200 feet.) Installation will serve: Residence a Co'mmercial r_ Other Number-of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: - _Water table depth SEPTIC TAMC �❑�Type/Mfg 'si- "�� Capacity_F No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation `] Property Line LEACHING LINE ❑ No. & Length of lines � ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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."Contractors 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." The applicant musfor all required inspections. Complete drawing on verse side. Signed Title: Date: + ♦ FOR DEPARTM T USE ONLY ? q� Application Accepted by Data �` �L J Area 22 i Pit or Grout Inspection by - Date inal Inspection b Date,�� -1 Additional Comments: ❑ Stk 466-6781 11Lodi 369-3621 El Manteca 823-7104 El Tracy 835 9!� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTEDC"Q INFO RECEIVED SY DATE PERMiT"NO. + EH 13-214(REV.101831 l y p EH 1428 a