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APPLICATION FOR PERMIT ' i • SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Io " Igse i Telephone 42091 466-6781 Q L3�y, �,11tIyLI�31.AL I'll-f3+l.l� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v[RVICES } 1 (Complete in Triplicate) Application is hereby made to the Sari 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. } � a Jab Address City Lot Size PM [, Owner's Name Address �©b ' e Phone Address Contractor .R B License No..9 r Phone a TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-Cl PUMP INSTALLATION ❑ SYSTEM REPAIR K OTHER%0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - 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 Dia. of Well Casing 1 Domestic/Private Gl Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �.-Approx'. Depth I-.I Eastern Surface Seal Installed by f - Repair Work Done Type-of- :: >i•P• ` i �±� State Work Done Well Destruction .�_ -Well Diameter •-- ._• Sealing Waterial (top 50- _, t I Depth ;J ;Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION I I DESTRUCTION 1 1' iNo septic system permitted if public sewer is ., r ¢ available within 200 feet.) v1 4; Installation will serve: Residence Commercial_ Other Number of living units: "" Number of bedrooms x Character of soil to a depth of.3 Meet : Water table depth rf O SEPTIC TANK I] ',Type'/Mfg Capacity No. Compartments 4J ! PKG. TREATMENT PLT. El of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ �No. & Length of lines Total length/size ' FILTER BED` U Distance to nearest: Well Foundation Property Line 'e SEEPAGE PITS I I "`D-pth z `Sizer Number SUMPS '❑ Distance,to#nearegt: fWell; Foundation Property Line a DISPOSAL PONDS ❑ 4• 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 I rules and regulations of the San Joaquin Local Health District. d. 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 comp nsa- tion laws of California." The applicant mu or all required inspec' Co ete d ing on reverse side. Signed X illi: ` Date: FOR DEPARTMENT USE ONLY Application Accepted by ' _ Date Area Pit or Grout Inspection by to Final Inspection by z"�f /�' _- Date/ 494 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f ' FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. t INFO +.EH 13-24 tREV.1/H 57 3—373 EH 1428