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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �'� L T ON AVC. 1601 E. HAZE , STOCKTON, CA Telephone (209) 466-6781 AUG 3 1-00 PERMIT EXPIRES TYEAR FROM DATE ISSUED WRON' [EN i AL HEALTH (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 escnlje&This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 7862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distric Ci Lot Size PM Job Address Na / y �ddress Phone Owner's �/} / e License No. Phoneq g tt r WELL REPLACEMENT ❑ DESTRUCTION ❑ j TYPE OF WELL/PUMP: NEW WELL C1W PUMP INSTALLATION ❑ SYSTEM REPA�� OTHER ❑ PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �-� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDEDSU E j TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,a.�,,,�y ❑ Dia. of Well Casing Industrial ❑ Open Bottom ElManteca Dia..of Well Excavation �Tlestic/Private ID Gravel Pack C] Tracy Type of Casing Specifications n Public Cl Other FIDelta Depth of Grout Seal Type of Grout r I Irrigation Approx. Q h ! ern Surf ace Seal Installed "I 111�>< P. ! e rte, Repair Work Done Type of Pum J�*�" "�f kWell Destruction ❑ Well Diameter" Sealing Material Itop 50'1 Depth Filler Material IBelow 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1. REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Y �.6 r-�..�..� -�,-_-•��- available within 200 feet.) 1 Installation will serve: Residence— Commercial— Other e Number of living units: Number of bedrooms v Water table depth Character of soil to a depth of 3 feet: (^ SE?TIC TANK L1Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: k well, 5 r Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ distance to nearest: ['Well Foundation Property Line SEEPAGE PITS l I Depth Size j ' Number I SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS- ❑ _ i 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. "I certify that in the performance of the work for which this permit issued, 1 shall not Home owner or licensed agent's signature certifies the following: ompensation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's c 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 compansa- tion laws of-California.' - -• -- -- - I The applican est lPIK required inspections. Complete drawing on rev side. Date: FOR DEPARTMENT USE ONLY ;��Z.Aroa Application Accepted byDate Pit or Grout Inspection by Date Final Inspection by Date � �p yd 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 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE LPERMI,,JT'NO. INFO +.EH 53-24 IREV,I I H 51 ` � EH 14-29