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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6 781 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 Rules and Regulations of the San Joaquin Local Health District. 4ehm Job Address✓ 9 3 �� City �� 7 _ Lot Size PM Owner's Name?4a- )-W_ kress ^ / Phone Contractor.- '-�• i' Address i`��' License No,C_-2-3 2 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ED Other ❑ Delta Depth of Grout Seal Type of Grout E41 rrigationN", --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done` D Type of Pumprir.Z H.P. 5` State Work Done (,2,—.,4 Well Destruction ElWell Diameter Sealing Material hop 501 Depth Filler Material (Below 50') TOF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION F) DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation wil Residence_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of linesTot th/size FILTER BED ❑ Distance to nearest: Well Foundation Prope e SEEPAGE PITS EJ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 subjecrto 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 applicaft)must II for all r Ired inspections. Complete drawing on reverse side. Signed X V-0. y' 1 1itle �� Date' s-If d OR DEPARTMENT USE ONLY Application Accepted by avlA, Date Z`0 Area (J _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CK CASH RECEIVED BY DATE PERMIT NO. + EH 1324 IREV.I/as) 1 EH 14.28 ��2�