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wAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA s .` Telephone (209) 466-6781 f AIJ G 2 31984 PERMIT EXPIRES 1. YEAR FROM "DATE ISSUED.." (Complete in Triplicate) LOCAI P P Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hreln`des #ibedT#iis 8pplion 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`Shh'Joaquin Local Health District. a0 ' � � � l T Jab Address � � " �_� _ City Lot Size PM- Owner's Name T7 Address �/� Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR K. OTHER ❑ f TDISTANCE Td REST: SEPTIC TANK 1 SEWER LINES YDISPOSAL FLU. PROP. LINE NEA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1Industrial LJOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ' ❑,Tracy Type of Casing Specifications { ❑ Public ❑ Other r ❑,Delta Depth of Grout Seal _ Type of Grout 1. ❑ Irrigation ---Approx. Death ❑.Eastern Surface Seal Installed by ` L Repair Work Done 4 Type of Pump H.P.It ` State Work Done `1 Well Destruction ❑ Well Diameter Sealing Material (top 501 oQ Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Residence_ Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments P Method of Disposal c KG. TREATMENT PLT. ❑ Distance to nearest: Well-.Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line } SEEPAGE PITS ❑ Depth Size Number SUMPS _ ❑' -Distance to nearest:'T -Welf�'-- " Foundation=`---�"l= T- Property-Line`- DISPOSAL PONDS ❑ F 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. 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 persona subject to workman's compensa- tion laws of California." ,The applicant t call for all required inspe ions.t� o late drawing on reverse sid /{ Signed C Title: h+' Date: FOR D PARTMENT USE ONLY y Application Accepted by �"� Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED UK 11;CASH RECEIVED BY DATE PERMIT`NO. INFO +Eli 13.24[REV.101831 S `` EH 1426 6