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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 applicatior 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 Joaq Local Health District. 2 S Job Address City ( Lot Size PM _ Owner's Name V 7�[K 6�(lY1Q– �yddress d ./. , 1�. Phone Contractor ��'�t/. �1 Address 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 ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public M 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 . l Well Destruction ❑ Well Diameter Sealing Material Itop 501 y Depth Filler Material (f3elow 50') 'f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION ! No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence____ Commercial Other t Number of living units: ,, Number of bedroom / / Character of soil to'a depth of 3 feet: Pk� /Water table depth 0 SEPTIC TANK ❑ Type/Mfg 2� "O 4, Capacity. No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Dri_sposal / Distance to nearest: Well Foundation 40 Property Line J I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation__A Property Line SEEPAGE PITS I I Depth �Z Size 'z /D Number �^ SUMP L� Distance to nearest: Well f Foundation 2? X��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, 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signal 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 comper tion laws of California." The applic mus call for all requ)ISPed irnspections. Complete drawing on reverse side. / Signed X Title: ✓ Date: f—�! FOR DEPARTMENT USE ONLYil i -- Application Accepted by --1/ Dat –Area Pit or Grout Inspection by Date_ Final Inspec on by � Datee`7_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P�EER�MITT'N�'O. ..EH 13-24(REV.riNsl �A,&Z� / // 9N- 264V yy Y/[S