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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 12091 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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District. p / Ali) � `f��c l�� PM Sal Job Address City Lot Size Owner's Name f` Rfl rens Phone Contractor � Address i ly�-57L2 License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial LJ'O.pen Bottom . C1 Manteca Dia. of Well Excavation Dia. of Well Casing E ❑ Domestic/Private L Gravel Pack ❑ Tracy Type of Casing Specifications U, ❑ Public R Other- L1 Delta Depth of Grout Seal Type of Grout I I Irrigation - —'Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done , Well Destruction ElWell Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR! DITION DESTRUCTION I 1 iNo septic system permitted if public sewer is �.-� .�. ..,,,. . -...r.. available-within 200-feet:) 00 Installation will serve: Residence_ Commercial_.. Other Number of living units: Number of brgoms � �(� ` N Character of sod to a depth of 3 feet: Water table depth I, SEPTIC TAMC El Type/Mfg ' ;Capacity -' No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines ' Total lengthlsize i i FILTER BED ❑ 'Distance to nearest: Well Fdundation Property Line SEEPAGE PITS Depth A Size - 3 Number SUMPS L-1Distanceto nearest: Welf` ~ Foundation Pr perty Line f p 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 Di1trict 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 k' employ any person-in such manner as to become subject.,to workman's compensation laws of Cal�fofnie."Contractors hiring or sub-contracting signature certifies the following: I'certrfy.that in the performance of the work for which this.permit is issued, I shali.employ persons-subject to workm'ans compensa tion s - laws of California:' t *, i..a.••K...x --ter `d w "' The applicant must all for. IJIrequire n�pections- Complete drawing on-rd0rs side.- .-j;11 JA Signed X ) Title: Date: FOR DEPARTMENT.USE-ONLY Application Accepted by - Date f -� Area ' Pit or Grout Inspection by Date_ `Final Inspection by' Date i. !!! I 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 v FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DP1`E PERMIT NO. INFO �] +.EH 13-24 I REV.1/R 51 /Gr� EH 14-28 r