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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) is madle�n Ion is complitance wieieby th Sanade toJoaqu nthe SanCounty Ordinance No. 549 for sewage or permit No 1862 for construct and/or pump and the Rules and Regulations of tthe Sanapplication Joaquin Local Health District. Job Address _ L9I&W �--x--�— s� "WJ"' City r D Lot Size PM Owner's Name -�•l il�Tl�.iTrQAc Ph ne Address �35 1 `T g7�. 4 Z 79 License N . 1337 Phone Contractor S L 1 Address •0•��=`'~i" i icense No. TYPE OF WELL/PUMP: row NEW WE WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER4f+t'e_ 0 DISTANCE ,�, TO NEAREST: SEPTIC TANK �+ SEWER LINES — DISPOSAL FLD. "� PROP. LINE _ !0 l FOUNDATION AGRICULTURE WELL OTHER WELL 4t2 PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q r ❑ Industrial ❑--//Open Bottom ElManteca Dia. of Well Excavation ~ Dia. of Well Casing ` f VDomesticlPrivate (]YGravel Pack ❑ Tracy Type of Casing Specifications M Public ll Other �71 Delta" Depth of Grout Seal a Type of Grout I I irrigation 11-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ll REPAIR/ADDITION E I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK OI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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: "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." s The applicant must c II for all required ins cti s. Complete drawing on reverse side. r k � Signed X Title: Date: FOR DEP TMENT USE ONLY Application Accepted by Date Area Ly�— i Pit or Grout Inspection by, G Date '1�� _ Final Inspection by to Date t Additional Comments: ❑ Stk 466-6781 ❑f Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PA:►Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO '7y + EH 13-24(REV.s i M 5) l EH 14-2e s