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t APPLICATION FOR PERMIT ' .SAN JOAQUIN LOCAL HEALTH DISTRIL r 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES T YEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hoieby 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. �� City 47 Lot Size_ PM Job Address Pp � I tGi _ \ i F' j (� �pdahl, LA-445— Lt Qd[� Phone Owner's Name �� ---- Address �1 r� i� � �! ! � Phone Contr Address �—, License No. TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION •1A SYSTEM REPAIR ❑ OTHER ❑ ! SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� ❑ Industrial l�Open Bottom ❑ Manteca Dia. o7Well ExcavationDia. of Weh Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyType ng Specifications /!v DD X ( I Public ll Other F1 Delta Depth of Grout Seal Type of Grout {�Llrrigation 5-10' Approx. D�eptthi I Eastern Surface Seal installed by Repair Work Done (2 Type of Pump tQl ► � — H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 y Depth Filler Materia! (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200 feet.) IN Installation will serve: Residence.— Commercial— Other r Number of living units: Number of bedrooms \� Character of soil to a depth of 3 t t: Water table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to n rest:' Well Foundation Property Line i LEACHING LINE ❑ No. & Length of li es Tota! length/size; r FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line F R SEEPAGE PITS l I Depth Number Size ,� l SUMPS Ll 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. Home owner or licensed agent's signature certifies the following: "l 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, l shall employ persons subject to workman's compensa- tion laws of California." The pplicant m s call fo all r uir inspections. Co4nplete drawing on verse side Title: Date: Signed FOR DEPARTMENT USE ONLY Application Accepted by / ,�; � Date _4a ` Area � Pit or Grout Inspection by •✓� Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT R ITCED CAH RECEIVED 6Y DATE PERMIT NO. ��:- t INFO 11(REV.$1N5) � X/n/ a�_/6G