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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT u pa 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 Rules and Regulations of the San Joaquin Local Health District. Job Address City SPTA;-N,,_ Lot Size PM Owner's Name '� �� Address Phone Contractor's Name - License No. 4-5 1/5 if: Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMP._INSTALLATION ❑ SYSTEM REPAIR,❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES, _ DISPOSAL FLD., PROP LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 41i� f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public . ❑ Other ❑ Delta.�r Depth of Grout Seal Type of Grout —Approx. Depth ❑ Eastern Surface Seal Installed by El Irrigation ° Repair Work Done ❑ "Type of Pump'. H.P State Work Done v r c Well Destruction ❑ Well Diameter! Sealing Material {top 50'1 s Depth Filler Material {Below 501 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION)( DESTRUCTION ❑;,(NO septic system permitted if public sewer is } "'available within 200 feet.) .� in' ta{laiion will serve: Residence I. Commercial Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: - "Water table depth = ' SEPTIC TANK ❑ Type/.Mfg Capacity No. Compartments l PKG. TREATMENT PLT. ❑ �r c Method of Disposal Distance to nearest: ,,,Well ; Foundation Property Line y ! Y �r Total len h/size LEACHING LINE � fv �y No. &Length.aflines� '� 9t FILTER BED `x'` O Distance to nea_rest: Well �! ;' ,Foundation- Property Line' SEEPAGE PITS �' Depths Z6 " Size Number • / SUMPS . ❑ Distance to nearest: Well r 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 y 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 must call for all required in p` ' ns. omplete drawing on reverse side. .e Signed X Title:�I= �' Date: g; FAR DEPARTMENT USE ONLY Application Accepted by ` Date — Area Pit or Grout Inspection by _ Dater2� "' Final Inspection by Date Additional Comments: ❑ Stk 466-67$1 .. ❑ Lodi 369-3621 ❑ Manteca V31Zb34 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , Stk., CAS FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO F[ y S +EH 13-24(REV.101831 EH 13-28