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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I l 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 isi 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. Job Address / v �Cn� �� City �'� �� Lot Size PM Owner's Name -! _ �f'� � Address _ tom-r-�-��L� Phone 7µi " 7 . _ Contractor�'�lr;l�'—c� �®��.�,��Address._�� J 3 fJ J?� a��License No.,7—,6 Z' 2`7 Phone .9-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM_R_EPAIR ❑'� i. OTHER ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES R DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C k+ i ❑ v\ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter `Sealing Material {top 501, 3 Depth Filler Material (Below 501 F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_,�_ Commercial_ Other Number of living units: —/_ Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ( Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal , Distance to nearest: Weli Foundation Property Line s 'JLEACHING LINE No. $ Length of lines © Total length/size.- --FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth Sizer ��e Number SUMPS ❑ Distance to nearest: Well 6ij.C.��-'•Foundation f� 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 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." The applicant must call for all required ins ctions. Complete drawing on revers99_1ide. g Si ned .4'+c-r c�� Title: -/.L�" r Date: < FOR DEPARTMENT USE ONLY > Application Accepted by Date T r -7 Area Y Pit orrGrout Inspection b :Date -Final Inspection by Date Additional Comments:Z Z ❑ Stk 466-6781 ❑ Lodi 369-3621 Ekffilintece '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 CK RECEWED BY DATE PERMIT'NO. INFO + EH13-241REV.1/857 7 0. 0 3-y_�-j �.-S� -. EH 14-28 !