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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 4W6781 PERMIT EXPIRES 1 YEAR FROWDATE 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 Ryles and Regulations of the San Joaquin Local Health District. �y i JobAddress iJ /� !J/� �j/1f' _ City MIO& X'G Lot Size PM Owner's Name gb ' Address Phone O Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION: SYSTE 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 ❑ I dustrial El Open Bottom ) Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑� �Gravel Pack ❑ Tracy Type of Casing _' Specifications Fblic 77IB'Other ❑ Delta Depth of Grout Seal �S V _ Type of Grout gation IrApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done it Well Destruction." - Well Diameter Sealing Material (top 501 Depth L2f) Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �` L Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of0isposal Distance to nearest: Well Foundation Property Line �t `J LEACHING LINE ❑ No. & Length of lies 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 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: "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." The applicantmm�ustt call for all req d inspections. Complete drawing on reverse side. Signed X L _i ,t,_ e2 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by A` Date ' 5— Area 2) I3 Pit or Grout Inspection by rY Date Final Inspection by ' Date Additional Comments: r^"' ❑ Stk 466-6781 ❑ Lodi AN-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: nvironment I Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REt�A1TTE; CK RECEIV 2Y DATE PERMIT 1V0. INFO ,BASH + EH 1428-REV.i/s 5} ✓ 13 r