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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED i (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. i Job Address City { Lot'Size` `�' PM 1 Owner's Name� ��i .��._- Address Phone Contract Address 1. {p ( y �G r License No. Z Z Phone u`S d� TYPE OF WELL/PUMP: !! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r ' ., PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINED} 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� 9 Specifications f, M Public n Other '❑ Deka Depth of Grout Seal Type of Grout I f Irrigation �IlApprox. Depth ( 1 Eastern Surface Seal Installed by Repair Work Done ❑ Typr of Pump H,P. State Work pone Well Destruction . ❑ WellIDiameter Sealing Material (top 501 u Depth Filler (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is j' I, available within 200 feet.) �--- :•k Installation wilt serve: R enc Commercial �p O h Number of living units: Number of Odrooms 1 �. iai Character of sail to a depth of 3 feet: �';��syr1_- � Water table depth _ ` [ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �I' l 1 Method of Disposal i Distance to nearest: Well Foundation Property Line ! LEACHING LINE `k No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITSD`pth Size � Number SUMPS l.7 Distance to nearest: Well._ i &` 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 I 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 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." I The applicant t call for all r ired spections. Complete drawing on reversesid Signed X , r ` Title: r Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date ?-9-0 Are? Aor Grout Ins pection by Date� �Final Inspection by - ate/& 75ar Additional Comments: - ❑ Stk. 466-6781 ElLodi 11369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit IServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. CASH INFO EH 3-24 I� + EH 11-28(REV.1/ 5; r f�rC 46