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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address 7v n Cit Lot Sized PM ' Ot LL Q Owner's Name � Address � 0 '� jam• __ _— Phon ? 7>`"_8 Z– Contract lctr r r Addressa • License No.7 G- Z_Z(P PhoneWo 5�G TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTPiNCE 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 _. I I Irrigation _--Approx. Depth l I 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 r Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTAL 1.1 REPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feel I Installation will serve: Rest encs Commercial_ Other Number of living units: Number of oms Character of soil to a depth of 3 feet. Water table depth lJ SEPTIC TANK Type/Mfg f r Capacity Q�� No. Compartments PKG. TREATMENT PLT. n {�} f �, Method of Diposal distance to nearest: Well Foundation Property Line s ' 1 LEACHING LINE No. & Length of'lines.' Total length/size 11420XIZ FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE ITS Depth Size _ Number r f SUMPS Irl Distance to nearest: Well l joo Foundation fry 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: "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: '9 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." call for q "ed inspections. Complete drawing on revers The applicant�XIs' l Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �l� Area or Grout Inspection by� Date Final Inspection by Date �__r CCCCCC//////Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 IEEE AMOUNT DUE AMOUNT REMITTED CK f U V RECEIVED BY DATE PERMITNO..CASH + ER 13-24(REV.r/R 5Cy` K I — IT—ql [ `' 'NQfEH 11-28 c rr