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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T 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 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. Q Job Address � � 6v� ( City Sl /v Lot Size PM // Owner's Nam��e�,,�r� Address /676C Jf lywtK 99„ Phone Contractor�J[iAl COA67 Address License No. Phone 2 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 ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed_ by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ? , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Et—DESTRUCTION ❑ (No septic system permitted if public sewer is available within_ 200 feet.) Installation will.serve: Residence— Commercial. '�ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity's_ _._ No. Compartments PKG. TREATMENT PLT. ❑ /�c�U �� ' 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 ❑ hereby certify that I have prepared this application and that the work will be done iq 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 lavts of California."Contractors 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 applicant must call for all required inspections. Complete drawing on reverse side. Signe/ / ` Title: � Date: v .FOR DEPARTMENT USE ONLY Application Accepted b Date Area r Pp p ea Pit or Grout inspection(y Date Final Inspection by Date Additional Comments: gr ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑.Mar"ca 823-7104 ❑Tracy 835-M Applicant- Return all copies to: Environmental Health Ps nit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMED RECEIVED BY INFO A . DATE kPERMIT'NO. CS+.EH 13-24(REV.1/85) EH 14-28 / (� �l j