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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT d 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {2091 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 f Local Health District. Job AddressCity Lot Size PM Owner's Name49 9� A dress - Phone .20 1) - J Contractor Address 4 ' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑` J ',,_WELL REPLACEMENT a DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 - DISTANCE -DISTANCE TO NEAREST:,SEPTIC TANK_ _ _SEWER-.LINES., ..._-. -DISPOSAL FLD. PROP..LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t Open Bottom ❑ Manteca Dia. of Well Excavatiori Dia. of Well Casing y ❑ Domestic/Private O Gravel Pack fl Tracy Type of Casing Specifications C'l Public Cl Other � Cl Delta Depth of Grout Seal <` Type of Grout I I hrigation '- Approxi Depth-.wl,t-Eastern,—..Surface Seal Installed by - Repair Work Done ElType of Pump H.P. State Work Done T Well Destruction O Well DiameterSealing Material Itop 501 i " Depth Filler Material IBelow 50')� TYPE OF SEPTIC WORK: ;NEW INSTALLATION I I REPAIR/ADDITION L I %DESTRUCTION K INo septic system permitted it public sewer is � �� available within 200 feet.) �A Instaliation will serve: ��Reslden ce ,_Commercial.— _Othee. Number of living units: . Number of bedrooms Character of soil to.a depth-of 3 feet: Water table depth SEPTIC TANK ❑ `Type/Mfg r l j Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest:,r Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines , +. Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property fine 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 i certifies the following: "I cdrtify that in the performance of the work for which this permit is issued;l shall employ persons subject to workman's compensa- tion laws of California." I r The applicant must call for all required inspections. Complete drawing overse s' Signed X Date: R DEPARTMENT USE ONLY Application Accepted by_: Date J Area Cy Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 +r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE PERMIT-NO. INFO /,] �7 +.EH 13.21(REV.1/H 51 3'1 �� 4 f`ti /�. / / ''eer 00- EH 14-26 J `-'L