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F APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT a � 1601 E. HAZEL T ON AVE., STOCKTON, CA S k A't8" w Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tri' (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. °1 U r Job Address 2� �z� +1 `'B1�}�, Rb City Lot Size PM Owner's Name G i Phone ' Contractor CSW ` AddressQ License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ :. DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q, INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation4 a Dia. of Well Casing MI-D—omestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑.Other - i D Delta Depth of Grout Seal Type of Grout I'7 Irrigation --Approx. Depth 1.1 Eastern Surface Seal installed by Repair Work Done ❑/-Type of Pump H.P, State Work Done Well Destruction tJ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public slis + available within 200 feet.) Installation will serve: Residence_I.Commercial_ Other Number of living units: Number of bedrooms € Character of soil to a depth of 3 feet: F Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y 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 SEEPAGE PITS 11 Depth Size Number _ r SUMPS 0 Distance to nearest: Well -. Foundation Property Line DISPOSAL, PONDS ❑ a I hereby certify that 1 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 Di-strict. I Home owner or licensed agent's signature certifies the following. hal !o an '�I certify that in the performance of the work for which this permit is issued, shall not employ y y person in such manner as to become subject to workman's compensation laws of California."Contractor's I r'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 law alifornia." The ap (cant must call fo all req id inspections. Complete drawing on reverse side. Cy 1 Signed Title: Date: [ _ FOR DEPARTMENT USE ONLY r Application Accepted by DateA I _ Final Inspectrea Pit or Grout Inspection by Date Finion by_. S �r Date � ZO_ �f r c � Additional Comments: r ❑ Stk 466.6781 ❑ Lodi 369-3621 I ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant- Return all copies to.- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k I ` FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/m 51 EH 14-28