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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) lApplication 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 Rcles and Regulations of the San Joaquin Local Health District. Job Address __ City Lot Size PM Owner's Namey�� ' E� Address Phone Contractor 5;,/ Address r License`No. Phone. TYPE OF WELL/PUMP: NEW WELL ❑ AVELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O �. `„ SYSTEM REPAIR"❑llhh, OT'HERV©Y-" t Via, DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP_LINE;. � FOUNDATION �`" AGRICULTURE WELL OTHER WELL 1• PITS/SUMPS INTENDED USE TYPE OF WEL'L`S" 'tiPROBLEM,AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ 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 a- Type of Grout ❑ Irrigation , ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material Stop 50') I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet./ Installation will serve: Residence'`f�__Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑� Type/Mfg = .; ? Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE, ( Na. & Length-of lines _ -Total length/size--,.--- ! ; _ FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth = Size ' Number SUMPS r ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS '❑ I hereby certify tKat-hhave prepared this application and that the-work will be done-in accordance'With'San Joaquin-county ordinankes, state laws, and rules and regulations of the San Joaquin Local Health District. f Home owner or licensed ag`ent'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 follovSing:"I certify thatAlthe performance of the work for which this permit is issued;/shail employ persons subject to workman's compensa- tion laws of California." The applic t m call for all required inspections. Complete drawing on/rev a side. f� Signed Date' " FOR DEP RTMENT USE ONLY " Application Accepted by, Date �4 - X�,-Area y a. i.tion,,,-•,ir— _ 1.f y 1' •�1{ ;, 'P rel,'f `„ Pit or Grout Inspection by Date Final pection by " " Date Additional Comments: rn �� "� � � �•� r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635- . " % ,mac `O'. ` 1' Applicant- Return all copies to: Environmental Health Permit/Services 1601 t.Hazelton Ame__ .O. 60x,2008, Stk_ CA 95201 ' INFO ' AMOUNT DUE AMOlIN7 REMIT7EO k Cx ` ; ,i RECEIVED Y, DATE �: PERMITL + EN 13-24(REV. /B 51 .�; - -,y, EH 14,26 v �` ©4 1 �5.� -- y C' '_ ,� 3 O.- - 1