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k APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Lot Size __ Owner's Name dress " ~ t ` Phone Q2�& Contractor dress ense No. Phone TYPE OF WELLIPU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ +�4 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL# PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t ' Dia. of Well Casing } ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`7 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation Approx, Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P- State Work Done _ -•-r i Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth - Filler Material (Below 50') F j TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence I— Commercial Other f Number of living units: Number of bedrooms 1 _ Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments— PKG. TREATMENT PLT. ❑ f � Method of Di osa Distance to nearest: 11 Foundation., Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to ne a t: elf _ Foundation Property Line wf SEEPAGE PITS i I Depth IC7 A I ize Number SUMPS Ll Distance to nearest: Well 1A 19 0 Foundation 4 19 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 Di$trict. 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."Contractors hiring of 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 applicant must III for all requi i spections. Comp le a drawing on reverse side. D Signed X • Title: Date41 : OR DEPARTMENT USE ONLY Applicatiq,q Accepted by� Date`/ Area ,, rout Insy Date Final Inspection by taat�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT.REMITTED CA H RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.l i n s) 0,6d EH 14-26