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x . . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is.heteby 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. IL ,I C f Job Address City t Size C1 /& 1'M Owner's Name / Address Phone A License No. �—� Phone Contractor - Address —� TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. q ,, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Vv 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public 17 Other' ❑:-Delta Depth of Grout Seal Type of Grout - a I I Irrigation --_Approx. Depth l I 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION l 1 INo septic system permitted it public sewer is available within 200 feet.),, - ' Installation will serve: Residence Commercial_ Other Number of living units: Number'of bedrooms Cha ater table depth SEPTIC TANK ❑ Type/Mfg ity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell dation Property Line LEACHING LINE ❑ No. & gth of'lines IT,, I length/size FILTER BED.,. ❑ ante to nearest: Well Foundation Pro _1 in�ry'� SEEPAGE PITS I I Depth Size Number SUMPS LZ Distance to nearest: Well Foundation Property Line r 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 rifles 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." The applicant ust call for al—required inspections. Complete drawing on reverse side. Signed X +•y // Title: Date: F fi DEPARTMENT USE ONLY Application Accepted by Date fi Pit or Grout Inspecti71Z�* on y Data Final Inspection by Rate i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 Lr.w C-1:7rveh 4b e'1V1T4",+- FEE AMOUNT,DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO Is- + EH13-24{REV.rinse .r a EH 1426