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*i APPLICATION FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 2 8 INN PERMIT EXPIRES 'i YEAR FROM DATE ISSUED - H IR01'I IENTAL H ,LT (Complete in Triplicate) E�E vV1s Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the' otief�ifl� be�dy. s application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name !`�,.c `^�[� Address Phone — I �. -..-.. .�- j' —_�;rte,--• -... _,.. .»,.�x -T:e..»-.7..� .�. _.- . . . ,. Contractor ) Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL O. WELL REPLACEMENT EJ,� DESTRUCTION ❑ PUMP INSTALLATION 'S' " *SYSTEM REPAIR`❑r OTHER ❑ DISTANCE TO NEAREST: SEPTIC_TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION_: - AGRICULTURE=WELL -OTHER-WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s VIDOmestic/ ustrial C] Open Bottom L3 Manteca Dia. of Well Excavation Dia- of Well Casing Private F1Gravel Pack ❑ Tracy Type of Casing Specifications f Public f ' EI Other F1 Delta Depth of Grout Seal Type of Grout_ I Irrigation —..Approx, Depth l I Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump + H.P, State Work Done Sealiri Material Ito 50') Well Destruction ❑ Well Diameter 9 R -- , Depth r,. + y R Filler Material (Below 50'1 — TYPE`DF SEPTIC WORK: NEW INSTALLATION'Q_,,REP AIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet! -. Installation will serve: Residence_ Commercial r Other . I Number of living units: Number of bedrooms .. depth table de ter p ' Character of soil to a depth of 3 feet: 'Wa � SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �~ ;•• ^"--•-Distance-to-nearest:- Well--�—FoundationProperty Line ' j ' I _ LEACHING LINE El No. & Length of lines Total length/size I i FILTER BEDS ❑ Distance to nearest: Well Foundation Property Line P SEEPAGE PITS I i I Depth Size Number SUMPS { C 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 li nsed 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 per n i such manner as to.become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the loll wi :"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- Y Hon laws of C The applic t 'u t call for all r ired ins' ions..-.Complete drawing on Iv er aside. N Y Signed X Title: Date: j i FOR DEPARTIVIE USE ONLY ' Application Accepted by date Area t EEl Pit or Grout Inspection by Date Final Inspection by Date ' r Additional Comments: ` ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 f ❑ 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 REMITTED CASH RECEIVED BY DATE PFRM1T NO. INFO+.EH 13-24 rFEV.r i N 51 �� tnq ' LA ©' EH 14-2e U {