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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZE;_T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 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. l / Job Address / Cit tL9&Mat Size PM Owner's Name ddress Phone F,5 on r o ddress -Vv t e� License No d"t511p Phone%�� 6171 TYPE OF WELL/PUMP: NEW WELL`—❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ��\ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSu INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ><.I.TesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout__- I I Irrigation _.-Approx. D pth lI I a r Surface Seal Installed by - Repair Work Done ❑ Type of Pu � �" "'"5 � , State Work Done Well Destruction ❑ Well Diameter rf Sealing Material Itop 501 Depth Filler Material (Below 541 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence— Commercial_ Other ^1 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 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 Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONbS ❑ 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: "1 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 t all f12&5�4ec:�ra_s_ Complete drawing on re r e sicla. Signe d Title: Date: 141 FOR DEPARTMENT USE ONLY Application Accepted by 1 /' t Date Area 152// Pit or Grout Inspection by Date Final Inspection by ot,� Date f) Additional Comments: ❑ Stk 466-6781 ❑ 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 95241 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. INFO CASH +,EH13-24SREV.r/n5Y 3s 1 1 L1/3� ©- 00 _ EH 1426 1 �0