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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON 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 application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Pules and Regulations of the San Joaquin Local Health District. l Job Address / City Lot Size PM _0 6 Owner's Name 14264.j 17y Address Phone C Contractor mess r icense No.Y` Phone,- Q TYPE OF WELL/PUMP! NEW WELL. ❑ WELL REPLACEMENT DESTRUICTION F1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL i� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F Other C) Delta Depth of Grout Seal t Type of Grout I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by �I _ Repair Work Done ❑ Type of Pump - H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material itop50' Depth Filler Material fBelo ) i! TYPE OF SEPTIC WORK: NEW,INSTALLATION I I REPAIR/ADDITION 1 DESTRUCTION f I (No septic system permitted if public sewer is- t. s # ` available within 200 feet.) installation will serve: Residence Commercial_ Other t Number of living units: Number of bedroomsAI- - r --Character-of-soil to-a depth 3'feet-- e�table depth � SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size- FILTER-BED ❑ Distance to nearest: Well Foundation __ Property Line SEEPAGE PITS s i 1 Depth A2 Y,X-Si"a Number UMPS Cl 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,Jand 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 shallemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signa 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 st or all7eqUif8d i s ctions. Co at drawing on reverse side. Signe( X - - . __ _ g Title: L Date: 1 — FOR DEPARTMENT USE ONLY J Application Accepted by Date Aaea "-�r a 49 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy a35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazaiton Ave., P.O. Box 2009, Stk., CA 95201FEE + k CK INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1324(REV.1/8 5) �/7Z EH 14-2e t7