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APPLICATION FOR PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA -Telephone (209_) 466-6781 PERMIT EXPIRES .1 YEAR FROM DATE ISSUED . (Complete in Triplicate) .4., r 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...,,, {w /. fi�rr,,pp ,k •if h .},. Job Address City �� Z Lot Size tl PM Owner's Name rL Address Phone t� b Contractor's Name License No. Phone `43— TYPE OF WELL/PUMP: 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I L1Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation �' Dia. of Well Casing , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `° Specifications !- El Public ❑ Other e Ll Delta P Depth of Grout Seal M t Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern p Surface Seal Installed by Repair Work Done ❑ Type.of Pump } H.P. �State'Work Done Well Destruction •❑ AWell Diameter," Sealing Material {top 50'1 _ _f Depth. Filler Material IBelow 501 , TYPE OF SEPTIC WORK: ,NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is " l vaiiable within 200 feet.) } Installation will serve: ' Residence_ Commercial_ Other �,/,/�✓ Number of living units: "k Numberiof bedrooms Character of soil to a depth of 3 feet: Water table depth :SEPTIC TANK. "• ❑ Type/Mfg ; `' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' ' Method of Disposal w: wDistance to nearest: Well Foundation Property Line l �. F LEACHING LINE ❑ No. & Length-ofllines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation' Property Line ° � 1 SEEPAGE PITS Q Depth Size - A Number � SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 Sam Joaquin Local Health District. I* - . 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 fol g:"I certify that in the performance of the work for permit is issued,I shall employ persons subject to workman's compensa- r tion laws o alif nil." { t C The appli at call for all r pections. Complete drawin o side. Sed zvItle: Date: A i" 0 EPA TIIIIENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ` ! ❑ Stk 4664781 - '❑ Lodi- 369-3621 ❑ Manteca 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 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y DATE PERMIT'NO. INFO GASH ` L s + EH13-24(REV.10/831 F - • u - '/ (a/ 1 EH 1426 --