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APPLICATION FOR PERMIT 3 f _P1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA A� Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f "F 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.JJ ��,�, � � Job Address � City Lot Size PM Owner's Nameddress _�a .� Phone �� S 1 Contractor Address License No, gSf6 P h a n e TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �wza ! PUMP INSTALLATION " SYSTEM REPAIR ❑ OTHER ❑ ` /� DISTANCE TO NEAREST: SEPTIC TANK _ -?� _E_WER LINES --,—DISPOSAL FLD._ -ROP. LINE -- =•ti FOUNDATION AGRICULTURE WELL��" OTHfR WELL__L�_ PITS/SUMPS 1NTENDED,USE : . TYPEOFiWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El El Industria! w .-❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing j r )"Domestic/Prrivate Ai Gravel Pack ❑ Tracy Type of Casing Specifications «� I'1 Pubfc"'_., ?-_ ��" ❑ Othe 3,�jn' "` ❑ Delta Depth of Grout Seal 1Q � Type of Grout ___.. _. I I l(rigation._ ��A?p><ox. epth i I Eastern Surface Seal installed by PA— Repair Work-Done ❑ Type of Pump ] H.P. State Work Done Well Destruction ❑ Well Diameter_' - --_"Sealing Material atop 501 Depth �` ;'`� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve:"'Residence-' Commercial— Other i < rNumber of living units: : Number of bedrooms k, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg,- Capacity No. Compartments PKG. TREATMENT PLT. ❑ - f ._ Method of Disposal "" -- -Distance-to-nearest: Well----- --- --foundation Property Line 0 -No:-&-Length of lines - --- - Total•Iength/size LEACHING LINE - "��"" FILTER BED ❑ Distance to nearest: Well ! Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: 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 DiItrict. 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." Contractor's hiring of sub-contracting signature certifies the following: "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 California." The appli7an3etion,ss. Complete drawing on rever side. Signed X Title: Date: FOR DEPARTMENT USE ONL Ik ApplicatiAreaPit or GrDate Final Inspection by 1 D �Additiona ' C"r G /C)z ❑ Stk 466;678.,7. odi—369-362.1,��...❑ Manteca_ 7104 t ❑ Tr 835 63$5 - 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 CASH RECEIVED BY DATE PERMIT-NO. INFO �+� ' Z +.EH 13-28 1 .1/9 51 l l CID - fy) 1Z