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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - {Complete in 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 Local Health District. ' r Job Address �� Z44City Lot Size PM Owner's Name 1��` t��lv A/f. �tlF�ss ��one � Phone Contractor's Name License No. � � _3 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION $ V, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z-Domestic/Private �.❑ Gravel Pack 11 Tracy Type of Casing Specifications ❑ Public ,t` }❑`Other, ❑ Delta {°1 Depth of Grout Seal Type of Grout E3 Irrigation _ -----Approx. Dep h Eastern Surface Seal Installed by Repair-.Work-Done C3 T.ype of Pump � H.P. e ,3 State Work Done A;Xp� Well Destruction r '0 V4lell Diameter Sealing Material Itop 501 i Depth Filler Material (Below 501 TYPE OF:SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic;system permitted if public sewer is 1{ available within 200 feet.) Installation will serve: Residence_ Commercial___ 0ter'> Number of living units:,�- .; , Number of bedrooms `` f Character of soil to a depth of 3feef: "'" " `Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line f , LEACHING LINE ❑ No. k Length of lines Total length/size FILTER BED ❑ Distarice to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth( Size Number SUMPS 12Dlstance'to nearest: Well Foundation Property Line 31 DISPOSAL PONDS ❑ . It 111 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 agenf'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 applican st 11 for a quired inspection -Complete drawing reverse side. Signed itle: Date: FO DEPARTMENT USE ONLY Application Accepted by1A4 Date RIO Area_�J Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT°N0. C. ! + EH 1324{REV.10183) n�. i w '-�-s�- EH 1426 f Ir