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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /* •,� 1601 E. HAZETON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. / V Job Address f �1}"i - `3i{ f City N~ Lot Size PM 4. r, G e Owner's Name ,// 'rd s-1� Address - Phone a Y - 1001 Contractor Address License No- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR" ❑ OTHER ❑ JI DISTANCE TO NEAREST: SEPTIC TANK SEW INES DISPO LFL PROP. LINE \ I FOUNDATION AGRICULT WELL ER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CO TRU N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia ell Excavation Dia. of Well Casing ! ❑ Domestic/Private -_❑ Gravel Pack ❑ Tracy ype of Ca 'ng Specifications # ❑ Public �.❑ Other ; - ❑ Delta "Depth of Gra t Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Ea rn Surface Seal In tailed by - Repair Work Done ❑ Type of Pump H.P. .. . State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth } FillerMaterial (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I - available within 200 feet.) Installation will serve: Residence Comintercial— Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity,` ! No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 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 1 � S SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: #-Well Foundation. Property Line k DISPOSAL PONDS ❑ t 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. f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the workfor which this permit is issued, I shalt not I 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." r e appan st call f all required inspections. Complete drawing on reverse side. Signed ~ /" Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ZQnDate Area Pit or Grout Inspection by Date Final Inspection by . �`� Date—sem" � Additional Comments: ❑ Stk 466-6781 ❑ Lodi A&3621 ❑ Manteca 820444 ❑ Tracy 835-.6385 Applicant- Return all copies to: Environmental Health Permit/Services 16DI E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 } ` IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMn N0. ♦ EH 1324(REV.i/n 517.�� , sI ��1/*92 FI r1 , I EH 14-26 � ....�.. �.J\ m._._ C� / '"� - ,