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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address Cit Y t Size PM Owner's Name Address Phone ContractoQr F ry�f Address c Aicense No. Ys Phot r TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D.ISPOSAL.FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL______t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPEC IFICATIONS l Q Industrial ❑ Open Bottom ❑ Manteca Dia.�of Well Excavation_ ` : ' "' �- .,-,Dia. of Well Casing ❑'Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications Ll21rrigation kPublic ❑ Other ❑ Delta Depth of Grout Seal � _A wType of Grout pprox. Depth ❑ Eastern Surface Seal Installed by � � �- air Work Done', F1Type of Pump H.P. State Wosk Done, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence, Commercial— Other ¢ Number of living units: Number of bedrooms Character,of soil to a depth of 3 feet: r Water table depth SEPTIC TANK e�. { EJ Type/Mfg Capacity Compartments PKG. TREATMENT PLT. El o- P Method of Disposal Fr Distance to nearest: Well Foundationproperty'Line LEACHING LINE ,No. & Length of lines Total length/size t FILTER BED'' ❑ Distance to nearest: Well f __ FoundaSion, �..Properlty Line of SEEPAGE PITS C1 Depth# Size Number DBLIMPS EJDistance to nearest: Well Foundation Property Line ISPOSAL PONDS ❑ r Ihereby certify that I have prepared this application and that the work will be done in accordance�w' ittNan.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 followin certify pe p Ho to an ' g. "I certi that in the performance of the work for which1his permit is issued, I shall not employ y persoin in such manner as to become subject to workman's compensation laws of-California."Contractor's hiring orsub�ontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject t workman's compensa- tion laws of California." 7- -The applica t call f re uire spections. Complete drawing on reverse side. Signed .. _.�� y Title: Date: FOR pEP,ARTMENTUSE ONLY- Application Accepted by -,j y' e4 0 /„ Date r v Area Pit or Grout Inspection by "Date Final Inspection by ate Additional Comments: I" ❑ 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, 5tk., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE EPERMI'T.,NO- -Im EH 13-24(REV.I/B5) EN 1428Q O -7 �