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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 465-6781 PERMIT EXPIRES l 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- Job Address City at Size �{yrr, PM Owner's Name Address Phone ,CbMfactor / rid ess' "�� -+ License No. O J - ! hone Y S z TYPE OF WELL/PUMP: P1 NEW VVELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE (FOUNDATION AGRICULT RE W L OTHER WELL PITS/SUMPS INTENDED USE 4 TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ,t El Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications I'l Public-1 • ❑ Other • ' Cl Delta epth of Grout Seal ' Type of Grout ._ I I Irrigation _Approx. Depth I I E tern urface Seal Installed by - Repair Work Done ❑ ` Type of Pump H.P. I State Work Done_ n] Well Destruction f_1Well Diameter Sealing Material (top Bel 50'l `f Depth Filler Material ( TYPE OF SEPTIC WORK: .NEW INSTALLA ION I l REPAIR/ADDITION I I DESTRUCTION I 1 iNo 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 SEPTIC TANK LlType/MfgZt -C Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Diiysposs II 4 Distance ton rest: Well� Foundation V iProperty Linet bob... l� (� LEACHING LINE Ll No. & Length of lines I ` To I length/size T ] FILTER BED ❑ Distance to'nearest: ell -} Fou ation Property Line �7 i SEEPAGE PITS 11 Depth G Size N bar SUMPS Ll Distance to near t: _ Well Foundation" Property Line DISPOSAL PONDS- ❑ r 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 Satz Joaquin Local Health Di?trict. 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 stieh.manner-as.to become subject to workman's_compensation laws of.California." Contractor's hiring or sub-contracting signature certifies the following:'9 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." �-w�--- «---�-� r The applicant t p1l for"uired inspe ions. Complete drawing on reverse side. Signed X. = Title: f Date: 3 DEPA T USE ONLY Application Accepted by Date O^ Arae - ..� I Pit or Grout Inspection by� _ w wDate _z. Final lnspect'on by ( Date Additional Comments: 1--?7Z ❑ 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 t FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT No. j INFO Q' ..EH 13-21(REV."/n s) EH 14-26