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APPLICATION FOR PERMIT ,R SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED 0 (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ai�4t Jab Address City Lot Size g x T5 PM \�t Owner's Name D 41CAddress t I Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ NSTALLATIO�10 SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC-TANKSEWER LINES DISPOSAL FLD. PROP. LINE :i. FOUNDATION A RIC#4-URE WELL OTHER WELL PITS/SUMPS y INTENDED USE +�' TYPE OF.WELL PROBLEM AREA CONS RTJS SPECIFICATIONS ; Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta ' - z., Depth of Grout Seal Type rout I I I Irrigation _,Approx. Depth I-I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 R[PAIRIADDITION l 1 DESTRUCTION l o septic system permitted if public sewer is A x' a ilable within 200 feet.) 1 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 f SEPTIC TANK !e ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑" Method of Disposal l Distance to nearest: Well _ Foundation Property.Line LEACHING LINE, ❑ No. & Length of lines ` Total length/size FIETER"BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1. 1 1 Depth Size Number SUMPS .T. k ❑ Distance to nearest: Well Foundation Property Line r 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 of.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 permit is issued, I shall employ persons subject to workman's compensa- - ' tion laws of California." r E The applicant t call f r ions. Complete drawing on reverse side.- Signed ide:Signed X Title: 00-2At A,#Z— Date: � FOR DEPARTMENT USE ONLY ,( a Are "'' Application Accepted by Date Pit or Grout lnspe ion by Date Final Inspection byZ2fDate h ' Additional Commen . �1 ❑ Stk 466-6781 :1 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 AMOUNT DUE AMOUNT REMITTED CKA CofH RECEIVED BY DATE PERMIT NO. INFO / t ��— � + EH 3.24 IR iiK51 EH.14-2a