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APPLICATION FOR PERMIT D� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE-- STOCKTON, CA 3 RT Telephone (209)74&6-67811 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCA. (Complete in Triplicate) HEALTH DISTRICT. 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. Jib AddressJ4046 ©, I City �1 �.✓� Cot Size PM Owner's Name� Y►'►'T _ Address J-060Phone Contractor's Name Cl icense No. r� Phone b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �igation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done [00"' Type of Pump H.P. -:r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 4 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 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 3 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 r `Foundation Property Line -SEEPAGE PITS ❑ Depth Size - Number SUMPS ❑ 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 District. Home owner or licensed a ent'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 ' such ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the foll ing:"I cert' th in the performance o he work f ch this per it is issued,1 shall employ persons subject to workman's compensa- tion laws of alifornia." The applic t mus call a squired i ctio g on re rse s' "0' Signed XDate: FOR DEPARTMENT USE ONLY (` Application Accepted by Date �� O— Area 2 Pit or Grout Inspection by Date Final Inspectio Date Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 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 CASH RECEIVED BY DATE PERMIT'NO. 4 ( + EH W.%IREV.101831 `or -7 5