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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. p Job Address �� `I' itf#�,!%E'+ __ - City Lot Size PM Owner's Name �� © ! �r �e r Addresses Phone -Contractor -.5U f' Address License NowC� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I Other fl Delta Depth of Grout Seal Type of Grout _. I i Irrigation p.Approx+Depth I I Eastern Surface Seal Installed by Repair Work Done A Type of Pump nZA. H.P. _ State Work Done Z4,PL4" /'lJmr Well Destruction 171Weil Diameter Sealing Material {top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION { 1 REPAIR/ADDITION l 1 DESTRUCTION l VI septic system permitted if public sewer is I�. available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a dept4f 3 feet: Water table depth i SEPTIC TANK ❑ I'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal :Distance to nearest:, Well Foundation Property Line ,I - LEACHING LINE ❑ 4No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t`I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ p hereby certify that l have preparad this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of t e San Joaquin Local Health District. Home owner or license tF'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 I'F'ner as to ecome elect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: c rt that in mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calitor s` The applicant mut e i ctions. Complete drawing on reverse side, Signed X ;E Title: Date: ... FOR DEPARTMENT USE ONLY Application Accepted by �Cj� Date^'��"1 Area Pit or Grout inspection by I� Date Final Inspection by Date 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 95201 FEECK$t ! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMITNO. C'J"+ EH 13-24 iREV.t/x51 ' t ('EH 14-25 J