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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 ,1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i; (Complete in Triplicate) i 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. i Job Address �.+ � L�+' �] A� � Ci of Size " � t PM Owner's Name i r Address Phone ..1 J Contractor ddress [ License Na. 8�Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑F_ s SYSTEM REPAIR ❑ OTHER ❑ (DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "AG WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x ' El Industrial ❑ Open Bottom ❑ Manteca-,e- ..„Dia._of`'Well Excavation ( Dia. of Well Casing 0 Domestic/Private ElGravel Pack ❑ Tracy V Type of,'Casing I Specifications ElPublic LlOther ❑ Delta Depth of Grout Sell - Type of Grout ❑ Irrigation 'Approx. Depth EJ Eastern "'Surface Seal Installed by `'" Repair Work Done ❑ Type of Pump H.P. State Work Done g Well Destruction ❑ Well'Diameter Sealing Material (top 501 Depth Filler Material (Below 501 s i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is availabib-.ithin 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms. -. l �` t Character of soil to a depth of 3 feet: A Water table.'depth SEPTIC TANK s ❑1t�Type/Mfg Capacity 16.OQ No.Comp rtrnents cl , Disposal, r P €PKG. TREATMENT PLT ❑ ZJ " -- 1 Method of Disposal Distance to nearest: Well–4- Foundation. �_..- Property Line :LEACHING LINE ❑ No. & Length of lines Total length/size t ;FILTER BED ❑ Distance to nearest: ell /00 Foundation Property Line "SEEPAGE PITS ❑ Depth Size Number 1` 4 'SUMPS ❑ Distance to nearest: Well ALL—" Foundation�_ Prope y Line �• ;j 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, stafe jaws, and pules and regulations of the San Joaquin Local Health District. - 1 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`s"ub contracting signature certifies the following:"I certify that in the performance of t6'work for which this permit is issued, I shall employ persons subject to"workman's compensa z tion laws of California." The applicant ust call for I required spections. Complete drawing on reverse side. j Signed Ij Title: Date: t i FOR DEPARTMENT USE ONLY f - Application Accepted by .�– Date ~ Area I r j�N Grout Inspection by Date `Ftin'I I spection by Date "Additional Comments: ' ` , ❑ Stk 466-6781 `" ❑ Lodi 369-3621 ❑ Manteca x823-7104 ❑ Tracy 835-6385 { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. t �O t + EH 13-24 inev.I/a 5; 3 EH 14-26