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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I 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 Rules and Regulations of the San Joaquin Local Health District. Job Address /7` 7*city J, Lot Siz,,A��ep Owner's Name4-/4� ! !-� �~ ( AEL/Vddress Phone Contractor's Namt icense No. .2 / (Is Phone y TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK L�S]��]/VER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1)" AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONF,. . 11Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4101, 6111e, 9;4;&nestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—. Specifications ❑ Public ❑ Other ( ❑ Delta Depth of Grout Seal ^C T r ype of Grout ❑ Irrigation Approx. Depth EIE stern Su ace Seal Installed by Repair Work Done ❑ Type---Approx.of Pump H.P. ! State Work Done Well Destruction ❑ . Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW_.INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence .Commercial_ Other Number of livirig units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal r� 1 Distance to nearest: Well Foundation+ � Property Line � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. - fies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certi employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 applicaZmcalj�Swallrequired inspections. Com rawing on reverse side. Signed . Title: a=�' - Date: FOR DEPARTMENT USE ONLY ( ! Application Accepted byA Date Pit or Grout Inspection by Date Final Inspection by Date 1 � Additional Comments: 1 ❑ Stk 46"781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K# RECEIVED BY DATE PERMIT`NO. INFO CA + EH 13.24{REV.10!83) �� 1 t9 / 4 3 � r EH 1426 - ��