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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address City Lot Size �y PM Owner's Name Address �� Phone Contractor Address License No�7 73� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT L1 DESTRUCTION ❑ PUMP INSTALLATION&I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial ❑ Open Bottom ❑ Manteca t Dia. of Well Excavation 11Z Dia. of Well Casing 'Domestic/Private 5W Gravel Pack ❑ Tracy Type of Casing /4`C Specifications j n. Public F1 Other 0 Delta Depth of.Grout Seal /DC? T G'eJ7re/► i ype of Grout I I Irrigation Z_SCo.Approx. Depth 1 1 Eastern Surface Seat-Installed by O/Z Repair Work Done ❑ Type of Pump rue H.P. State Work Done Well Destruction C1 Well Diameter Sealing Material (top 50')-- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is „ available within 20D feet.l Installation will serve: Residence_ Commercial_ Other. C` 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 - `l SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `: I, 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 Di§trict. 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 s 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 re wired inspections. Complete drawing on reverse side. t Signed X I Title. ' —��Cns.. Date: 3 ARTMENT USE ONLY q� q Applicatio Accepted by Date Area Pit r Grout I �-^-- -�• � � - -- l pection ey` -� -Date Lf-13'�fl Final Inspection by .�_ 1 Date .2;:51 Additional Comments: '14 nysr (1 U WR r- 11 Stk 466-6781 ❑ Lodi 369-3621k ❑ Manteca 823-7104 ❑'Tracy 8315-8385 , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazella Ave., P.O. Box 2009, Sik., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r +-EH 13-21 IpEV,i/nsl D�eU �/ lo�.� ' D ( 0— l EH 1 -2i1 -'-t qu M