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APPLICATION FOR PERMIT, SAN JOA_ QUIN LOCAL HEALTH DISTRICT 1601 E. H'AZELT 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. 1 : � Job Address : —� City. Lot Size PM Owner's Name — Address i / ?7 014.7-0- )ZI-D Phone T� Contractor Address_9?1014e5i License No. Phone —3. TYPE OF WELL/PUMP: NEW WELL�j WELL REPLACEMENT ID DESTRUCTION ❑ PUMP INSTALLATION 91 SYSTEM REPAIR ❑ OTHER ❑ ��,/ DISTANCE TO NEAREST: SEPTIC TANK T( SEWER LINES DISPOSAL FLD ,PROP. LINE t -- 7 FOUNDATION � AGRICULTURE WELL — OTHER WELL��PJTS/SU S ��. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOPJS ❑ Industrial ❑ Open Bottom I] Manteca x Dia.-of-Well-Excavation _ Dia: of Well Casing I)e'Domestic/Private ravel Pack © Tracy 'Type of Casing } Specifications FI Public IA Other ❑ Delta Depth of Grout Seal mo i/ "f'ra /p/7 pe of Grout I t Irrigation �j�lLr�..Approx. Depth I ] Eastern Surface Seal Installed by � � _ Repair Work Done ❑ Type of Pump H.P. State Work hone _ Well Destruction 11Well Diameter Sealing Ma_�terial {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (:1 REPAIR/ADDITION l 1 DESTRUCTION I I 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 ❑ Type/Mfg r Capacity -,+ No. Compartments PKG. TREATMENT PLT. ❑ a-= Method of Disposal ? I Distance to nearest: Well Foundation Pro0erty.Line t LEACHING LINE ❑ No. & Length of lines --�" Total'((gth/size �d FILTER BED ❑ Distance to nearest: Well Foundation Property'Li'- '3 r SEEPAGE PITS I I Depth. Size �.Numbef SUMPS LI Distance to nearest: Well Foundation : PropertVILine DISPOSAL PONDS ❑ ;'s 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. e wo Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thrk 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 cartify 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 c .al requir " s ns. Complete drawing on-r=9 arse-side:. • � �`^�'"r"� Signed X Date: p� FOR DEPARTMENT USE ONLY 5 Application Accepted by e-_ Date "` Area Pit or Grout Inspection by bate -<4;ftFinal Inspection by r ? 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. +,EH 1 3"24(REV.1 i H sl Q Je— EH 14-20