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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL!HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. 4" Z Job Address ¢ City Lot Size L �� PM Owner's Name &,Ce 1�2 -19,A-tsS Address = Phone Contractor Address ?�'ti Y License No. ��!S'?i/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL:41DLACEMENT.❑,..'\ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM SYSTEM REPAI r -7 's`"a yOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - �'PITS/SiJMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom _❑.Manteca Dia. of Well Excavation Dia. of Well Casing (Domestic/Private C1 Gravel Pack.✓'' ❑ Tracy __-.Type-of Casing Specifications ❑ Publics ❑.OtherY`a ❑ pelta y Depth of Grout Seal `-'Type-of-Grout— LF,r-r'igation rout❑ Irrigation �pprox. Depth i ❑ Eastern `; Q Surface Sealgnsi sled by °w. Op Repair Work Done Type of Pump € H.P. State Work Done C. .� l f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) i —TYPE OF.SEPTIC WORK: `NEW'INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if,public_ sewer is • available within 200 feet.) L� stallation will serve: Residence Commercial_ Other } , Number of-living units: Number of bedrooms Character of soil to edepth of 3 feet: Water table depth t SEPTIC TANK O Type/Mfg Capacity No. Compartments -7 PKG. TREATMENT'PLT. ❑ Method of Disposal J h Distance to nearest: Well Foundation Property Line I � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS .❑ Depth Size v Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `1 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." s The applicant Mall for all equired inspections. Complete drawing on reverse side. Signed Title:- - Date: � � ' F DEPARTMENT USE ONLY Application Accepted by Date Area o C Pit or Grout Inspection by ' Date Final Inspection by a��, .a �ax hate k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑;Tracy 835-6385 1� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I a FEE INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY JJ.. DATE PERMIT`NO. + EH 13-24(REV.1/e 5) EH 1426