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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. I Job Address 11 �=� '� City Lot Size PM - - f f I , rU Phone Owner's Name Addre > a �J ? Cantracto Atldress� �S� 1kg26- 1_icense No.� � Phon TYPE OF WELL/PUMP: NEW WELL_D �. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _OTHEFI WELL _ -PITS/SUMPS: __ INTENDED USE_ J TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS >fIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public C1 Other + ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth �t I Eastern Surface Seal Installed by { Repair Work Done LJ Type of Pump 41 f .. H.P., State Work Don Well Destruction ❑ r Well Diameter ' '} sealing Material [top 501 Depth h Filler Maieriaf(Below-501-�--- =— I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I iNo septic system permitted it public sewer ism, I '� t available within 200 feet.) L Installation will serve: Residence J Commercial____ Other Number of living units: Number of bedrooms Cq 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 Foundation Property Line % LEACHING LINE ❑ No. & Le'ngth of lines Total length/size kFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance'to nearest: Well Foundation Property.Line DISPOSAL PONDS ❑ _ _ _ : _ _..,_ -,_� . - _"'.,.---..v ,;�, „�. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin co`u_nty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di%trict. Home owner or licensed agent's signature certifies the following:.- 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 rl shall employ persons subject to workman's compensa- tion laws of California." The applicant f r all required i ctions. Complete drawing on reverse side. Signed .� Title: 0124 Date: I OR DEPARTMENT USE ONLY l / / / � A > Application Accepted by Date Area_ T Date Pit or Grout Inspection by Date Final Inspection by E� Additional Comments: ❑ 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, Stk., CA 95201 rt r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦-EH 13-24(REV.1/9 5) EH 14-29