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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) 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q r I Job Address � � / City Lot Size ' PM_ Owner's Name �/`-1 �y v✓address �u Phoneme Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l` 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications L * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50'1 _ DepthFiller Material (Below 50'1 J' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITIONW DESTRUCTION I No septic system permitted if public sewer is / available within 200 feet.) - Installation will serve: ResiQence_✓Commercial Other Number of living units: /' Number of bedroomyr Character of soil to a depth of 3 [4y9��(•( Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V PKG. TREATMENT PLT. ❑ ��{f1 If Method ofDisposal Distance to nearest: Well�— Foundation ` Property.Line rose LEACHING LINE ❑ No. & Length of lines !V Total length/size .` / / / FILTER BED ❑ Distance to nearest /!YWell 9 Foundation Property Line SEEPAGE PITS 1 ) Depth iz Size /2 Number SUMP ❑ Distance to nearest: Well L Foundation 2M9X/21'roperty Line—L� DISPOSAL PONDS ❑ 1 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 applic t mus call for all requ' d i spections. Complete drawing on reverse side. J�/ Signed X Title: Date: ` / c"!r FOR DEPARTMENT USE ONLY "r7a Application Accepted by ` Da -rea Pit or Grout Inspection by Date Final Inspec on by Datg� _ Additional Comments: n ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 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 4 CASH RECEIVED BY DATE PERMIT'NO. Rp INFO i� s.EN b211REV,lixsl �/0 Q EN 1426 V/ 76, ( P65141-1- � 9 - gVyyAy_y-r L