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1 APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT t . O(pS C/ 3S0 1601 E. HAZII AVE., STOCKTON, CA CI Telephone (209) 466781 ' 1 J'".__p�'� PERMIT EXPIRES 1 YEAR FROM GATE ISSUED 1 (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. _,l '^ Job Address 1 +° - �'P'� City . Lot Size PM r: ' Owner's Name /Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ^V� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ6I Casing - - Spbcifications t ❑ Public ❑ Other ❑ Dehio Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern. Surfaoe'Seal Installed by Repair Work Done ❑ Type of Pump H.P. T State Work Done (� Well Destruction ❑ Well Diameter Sealing Material-Imp 509 ' Depth First Material (Below S0) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septicsyYstem permitted if public sewer is available wnhin 20D feet.) Installatiop will serve: Residence—',.Commercial_ Other ' Number of riving units:_ Number of bedrooms A ., _ W Character of soil to a depth of 3 feet: t - ` Water fable 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/siz '^T ' FILTER BED ❑ Distance to nearest: Well Foundation Property Une SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: "Well - Foundation - 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. t 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 Califomia."Contractor's hiring or subcontracting 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 inspections. Complete drawing on reverse aide. Signed " Title: Date: ,y , FOR DEPARTMENT USE ONLY Application Accepted by Data Area ' Pit or Grout Inspection by Date Final Inspection by Dote Additional Comments: - ' ❑ Stk 461 ❑ Lodi 3W.311211 ❑Manteca 823-7104 ❑ Tracy 035.6385 Applicant-Return all copies to: Environmental Health Poorrnit/Services 1601 E. Hazeiton Ave:;P.O. Box 2009, Stk., CA 95201 4- FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. «aFH 13.24(Ov.101931 +sI W26^'