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►rtl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E7- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781N�D"VC-111�� PERMIT EXPIRES 9 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 does ribed. This a Q made H compliance with San Joaquin Joaquin Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San J glz Local Health bis "c X pplicatrf iT, r� p � Joaquin rs Job Address City Size Owner's Name � 7 � PM Address J f Contrac � Phone ress TYPE OF WELL/PUMP: NEW WELL ❑ License No Phone q7 REPLACEMENT El PUMP INSTALLATION EJ WELL ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C1 OTHER EJSEWER LINES DISPOSAL FLD. FOUNDATION ` - AGRICULTURE WELL PROP" LINE INTENDED USE TYPE OF WELL OTHER WELL_ PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial � � ❑ Open Bottom ❑ Manteca '� Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing f'l Public ❑ Tracy Type of Casing C1 Other ❑ Delta Specifications I I Irrigation J Depth of Grout Seal t --_..Approx. Depth ! I Eastern Type of Grout ❑ Type of Pump Repair Work Done Surface Seal Installed by H P Well Destruction ❑ Well Diameter State Work Done_ Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION f DESTRUCTIONvT No septic system permitted if public sewer is Installation will serve: Residence--f Commercialavailable within 200 feet.) Number of living units: Other �� Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg y Water table depth PKG. TREATMENT-PLT. ❑ Capacity. No. Compartments Distance to nearest: Well Method of Disposal O I —�_ Foundation Property Line a" LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size _ I Foundation Property Line SEEPAGE PITS r.l i Depth SUMPSSize Number ❑ Distance to nearest: Well DISPOSAL PONDS [] Foundation�� Property Line r I hereby certify that t 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 employ any person in such manner as to become subject o workman's compensation laws of California."Contractor's hiring or sub-contracting signature �• certifies the followin permit is issued, I shall not g:"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." The applicant must cal fo pe ns. Complete drawing an averse side. . Signed X Title: f Date: l FOR DE ARTMENT USE ONLY Application Accepted by Da Pit or Grout Inspection by to Area Date—�. Final Inspection by l 2"Cr 3a Additional Comments: !O �� S 7 ` Date ❑ Stk 466-6781 ❑ Lodi 369-,13621 ! S9 'S" r A5-6385 (C-�. Applicant - Return all copies to., Environmental Health Peermit/Se cess 1601 E7104 Hazelton Tracy Ave, P.O. Box 2009 Stk., CA 95201 FEE MOUNT DUE I CK INFO MOAMOUNT REMITTED RECEIVED BY CASH DATE PERMiT'No. + EH 13-24 IRE'V,v�57 ' EH 14-26 `