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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 486-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete jn 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q Job Address City Lot Size PM Owner's Name Lr jn (31�+0�, l��c�� Address 9h?7 C �Ya� Phone al r Cantractor�4 ddress License No.� .SPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑� PUMP INSTALLATION SYSTEM REPAIR OTHER_L ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications VPublic ❑ Other n Delta Depth of Grout Seal Type of Grout_ (� I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ot Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feetA 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 ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS --.,.,; ,I_Depth Size .Number SUMPS Ll Distance to neatest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 perso n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies tha folio ing "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 Cali o a." The applicat all for all requ re inspecti Co late drawing o rave a side. Signed X Title: I elq Date: FOR DEPARTMENT USE ONLY Application Accepted by Data r Area i Pit or Grout Inspection by Date Final Inspection by Date l 1 Additional Comments: / ❑ Stk 466-6791 ❑ 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 INFO yAMOUNT DUE AMOUNT REMrTTEO C K RECEIVED BY DATE PERMIT N0. +.EH14-21fREV.tlH51 1��+� �f� �£-t Q .. 9C) EH N-� I i 1 I T;