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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT ` t{ 1601 E. HAZE.T ON AVE., STOCKTON, CA �+ Telephone (209) 466-6781 t [ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !� (Complete in Triplicate) oaquin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the San J nty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Cou Local Health District. L:-A-4— City Lot Size PM Job Address Address Phone Owner's Name � j Phone Contractor's Name ~V e n s e No.r ¢ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ly SYSTEM REPAIR ls�l OTHER ❑ 6 PUMP INSTALLATION ❑ r CI ►wr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE CJI FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL LU PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom S ❑ Manteca Dia. of Well Excavation Specifications m C3►pomestic/Private . PGravel Pack ❑ Tracy Type of Casing � ,t Type of Grout 1 '4 ❑ Delta Depth of Grout Seal Public w i.+. a.. ❑ Other W - �� ❑ Easterri� Surface Seal Installed byfi ❑ Irrigation i ---Ai :1116414 Dep .per _' State Work Done Repair Work Done f� Type of Pum ' S 5ealin Material )top 50'IJ ` Well Destruction ❑ Well Diameter 9 1. Depth -"-- Filler MateriSl-IBelow_5V. „- TYPE OF SEPTIC WORK: NEW INSTALLATION EJ y DESTRUCTION']-availahlelwith in200 feet.) permitted if puhlicsewer is Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKC. TREATMENT PLT. ❑ 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 l SEEPAGE PITS ❑ Depth Size Number j �. x SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. rtify that in the performance of the work for-which this permit is issued, ! shall not Home owner or licensed agent's signature certifies the following: "I ce f 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." 1 The applicant t call or all uireoinspections. CpAnplate drawing on reverse side. Date Signed itle: : l FOR DEPARTMENT USE ONLY Date ^1 Area Application Accepted by �..._.�- � Date s Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104yr ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 ? CK 0 t IFEENFO• AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24)REV.101831 '�'j 5 t' O 7 Il �� EH 14-26