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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L \ , 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) �$ b.► z � 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 I Local Health District. Job Address Z25e .246yQl4,f=_ Citof Size PM Owner's Name 6QL;e, ti Address Phone ' Contrac Addr ense No. Phan i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISI PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial L7.Open Bottom, _ —.L7 ca_ ___Dia, of Wel Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public° 17 Oth ❑ Delta Depth of Grout Seal Type of Grout 'n I I Irrigations _-.Approx. Depth 1 I Eastern Surface Seal Installed by lJ } Repair Work Don Type of Pump H.P. State Work Done Well 1) on ❑ Wel Diameter ` Sealing Material {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIO 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 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal J{ Distance to nharest: Well Foundation Property Line 1 LEACHING LINE'/, ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line l SEEPAGE PITS i I Depth Size Number SUMPS / Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 i 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 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 certify that in the performance of the work for which this perm-rt is issued, I shall employ persons subject to workman's compensa- i tion laws of California." i The applican ust call for all required ins do s. Complete drawing on revv se side. Signed r Title: [ _ ,� Date: R DEPARTMENT USE ONLY Application Accepted by a A �� .UAflrn,f� wn ,� Date g Area Pit or Grout Inspection by �{ Data �p Fin I Inspection by Date Additional Comments: 'v`' r � { © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 1 ; INFO AMOcUUN-T DUE AMOUNT REMITTED CK RECEIVED BY DATE ! PERMI7'NO. + EH 3 24 1REV.iin51 EH 426 s�U 3�•�fJ lrr,'ll. ��C7 1 ! II LY