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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAiEL T ON 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address t Jit City Lot Size PM il + . A� Owner's Name" Addressi�C � OC / 3 _ �Q Phone' t� ContractL� ,L@� [.[ Address 1 �.�f , X License No. °� ray Phone 67 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r ^� -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ,, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G ❑ Industria! „;❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 4::'v E1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public .�❑ Other . _ ❑ Delta_ Depth of Grout Seal Type of Grout ' ❑ Irrigation _�4pprox. Depth ❑ Eastern I Surface Seal Installed by Repair Work Done Type of Pump_ H.P. L State Work Done ; F� Well Destruction El” Well Diameter �� Sealing Material (top 50'1 UJa Depth p �'�� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -REPAIR/ADDITION' DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence Commercial-_ ther Number of living units:, { �.._ Number edrooms, Character of soil to a depth of 3 feet: 1 Water table depth �. : (� SEPTIC-TANK �..❑` Type/MfgGapacity No. Compartments PKG. TREATMENT PL7�❑ I '— Method of Disposal Distance to nearest:" Well Foundation Property Line LEACHING LINE IrlNo. & Length of-lines i Total length/size X FILTER-BED C) Distance fo nearest: Well iso- Foundation__10 Property Line S` SEEPAGE PITS 18<Depth t�3 Size 33 Number C SUMPS. ❑ Distance to nearest: Well '1001 Foundation 10 Property Line�E 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 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 st call for re uired inspections. Complete drawing on reverse side , w► ti i t 'Signed Title: 8's Date: � r a FOR DEPARTMENT USE ONLY [�f Application Accepted by ad Date Area 651 /1 Grout Inspection by Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Reiurn•all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ; INFO AMOUNT DUE AMOUNT REMITTED CKO _T CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/8 5) �y EH 1426 4 f] Z,na