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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �rrn 1 1601 E. HAZEL 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 appiication,ls 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 _ if 7 Iq A r # �' Citytl.ALot Size IR r— PM Owner's Name ' Address - Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well j xcaration Dia. of Well Easing 01, omestiNPrivate Gravel Pack ❑T�racy' '.Type of Casing Specificationsublic ❑ Other, ❑ DeltkDepth of Grout" e ,. Type of Grouf rigation;ti; r �Wppr x. Depth ❑ Easter? Sur ace Seal,Installed by + l. Repair Work D e '❑ Type of Pump F�f'� State Work Done ` r c r Well.Destruction �] Well Diameter_ Sealing Material 1fopR501) , f` I Depth F'iller,Materia! (Below°501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer ie., c available within 200 feet.) Installation will serve: Residence Commercial�x Other Number of living units: —7v— Number of bedrooms. 'a Character of soil to a depth of 3 feet: Water table depth ' J^ F SEPTiC TANK Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well Foundation "Property ' y LEACHING,LINE No. & Length of lines "' Total length/size .`9 FILTER BED ❑ Distance to nearest: Well g Foundation jL� Property Line SEEPAGE PITS ❑,'Depth Size Number t SUMPS Q 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." The applicant mus fo all re iredi tions. Conplete drawing on reverse side. Signed TIEPARTMENT itle:, Date: V . r'�� R U ONLY A Application Accepted by `' � rr I - T e. r Y Date T Area } I .Pit{ar Grout Inspection bye Date Final Inspection by Date 'r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-638,5 Applicant- Return all copies to:. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,CA 95201 e FEEAMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT•'NO.' INFO CASH - + EH 13-241AEV.40/19 S3=1303! y - R � . EN W26 '