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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA g Telephone (209) 466-6781 r 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address G City ' of Size Owner's Name Address r Phone [d Contractor's Nam - License No. Phone 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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bo��f,o_�mI-] MantecaDia. of Well Excavation f '- Dia. of Well Casing XDomestic/Private LJ Gravel Pac,,k0, ❑ Tracy Type of Casing Specifications .0.Public t ❑ Other 1' ❑;Delta Depth of Grout Seal Type of Grout IZY ❑ Irrigation �4pprox.(Depth ❑ Eastern Surface Seal Installed by "Repair"Work Done Du Type of Pump . H,P. State Work-Done We 11-Destruction ❑Well Diameter Sealing Material (top 50') Depth " Filler Material (Below 501LA '� s TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available"within 200 feet.) 9 Installation will serve: Residence Commercial_ Other A Number of living units:. Number of bed- ms 0 Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK ❑ Type/Mfg; apacity No. Compartments PKG. TREATMENT PLT. ❑ ,re ,{ Method of Disposal Distance to nearest: Well 6_D Foundation -Property Line/S-_ LEACHING LINE ' No. & Length of lines 772 Tots) length'/size p` FILTER BED 3 Distance to nearest: Well Foundation Property Line a SEEPAGE PITS Depth _ Size_ Number_ s I SUMPS ❑ Distance o nearest: Well Foundation PrZIP ry Line J DISPOSAL PONDS ❑%_ 11, r) L_ r I hereby certify tliat,l have prepared this;application and thatathelwork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations oflhe-San Joaquin Local Health,Distrlct. 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 to1become subject to workman's comperisation laws of California."Contractor's hiring or sub-contracting signature I certifies the following: "I certify that in46e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Caiifoka." ; ,! The applicant uit call for all raqui in ctions. Complete drawing on r rse sideOF . Signed g Title: V . Date: -2 � ARTMENT USE ONLY Application Accepted by Date. Area Pito Grout Inspection,by 1.: o mate -�, �5 Final Inspection by G�ny4r,, �. .M. ,lNerntA Date 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CKSH C A RECEIVED BY DATE PERMIT"NO. S l s X37". 21g1 F.5-- �7� + EH 1324(REV.toiml EH 1428