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n APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT Fj 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . Job Address City Lot Size PM i T�Q Owner's Name _(__�/ �� Addrbss�'�'` Phone � S t Contractor S' Address {cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIRW OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F 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 FPublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout F ❑ Irrigation --Approx. Depth ❑ Eastern Surface-Seal.Installed by Repair Work Done ❑ -Type of Pump �lfl/o Staterk Dobe e4- Well Destruction 13Well Diameter- —• - Sealing Material (top 50') Depth fitter Material (Below 501 , -._1� ?(-� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve Residence_ Commercial— Other # j Number of rovingunits: Number of bedrooms Character of soiltoa depth'of'3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I CapacityNo. Compartments PKG. TREATMENT-PLT. El ?.' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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. Home owner or licensed agent's signature certifies the following: "1 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 applicantr requi ctions. Complete drawing o eve side., Signed Title: _— �✓ Date: l FOR DEPARTMENT USE ONLY " Application Accepted by <S�Zzl, Date �ri Area Pit or Grout Ins J pection by Data Fina! Ins'p'ection byt Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 83546385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED _,c CASH. RECEIVED-BY;=' DATE PERMIT"N0. + EH13-241REV.1/0 5) EH 14-2e � L