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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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.V r �tA �Job Address � �� city Lot Size PM Owner's Name Address r 1,L7_/ 2./X/�3 Phone t 5912 Contractor w Address V`, a C License fro. . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ S TEM REPAIR 11OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARI CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other MI Del Depth of Grout Seal Type of Grout I ] IrrigationApprox. Depth I 1 E tern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l ]� Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �} r SEPTIC TANK ❑ Type/Mfg city No. Compartments PKG. TREATMENT PLT. ❑ t4Method of Disposal Distance to neare t: Well Fou tiori Property Line , LEACHING LINE Cl No. &Length of lines _ Tptal length/size ` FILTER BED ❑ Distance to nearest: foundation Property Line SEEPAGE PITS l I Depth Size N mbar -SUMPS [--IDistance to nearest: Well "Wil? Foundation_ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application arid 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."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 ail required in coons. Complete drawing on reverse sidg. Signed r Title: - - Date: . f ^id y DEPARTMENT USE ONLY I . ,— �? / Application Accepted by DateJ, i >� Area !).4 All F Pit or Grout;Inspection by j Date Final Inspection by, 1T� fes, � Date Additional Comments: ❑ S* 466-6781. ❑ Lodi 969-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO +.EH14-24[REV.sins) _ S-'�0 EH 14-2(1 �l 7 I OL• I