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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 Regulatio s of the San Joaquin Local Health District. 'i Job Address /^0. 1 e— 4�2 City �^C� �!l Lot Size O PM Owner's Name 1 Address Phone Contractor ✓ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { 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 C1 Industrial ❑ Open Bottom:.. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy -Type of Casing Specifications I`1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout-- 11 routI1 Irrigation -Approx. Depth i I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITIOW DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other .Number of living units: -- Number of bedroomsO' '�� t- character of soil to a dept 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 i ACHINGLINEt� No. & Length of lines Tom length/size 1 g FILTER BED ❑ Distance'to nearest: Well f=oundation: Property Line z 1 It SEEPAGE PITS I I Depth 'I _ Size y�mber 5U t� Distariceeto nearest: Well�_ ]_ Foundation Property Line A!5 _ - DISPOSAL PONDS ❑ 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. i 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion laws of California." The applicant m swim a quir ctions. Complete drawing on reverse side. " Signed _�. Title: Date: -Z �^ i FOR DEPARTMENT USE ONLY Application Accepted by ff<9 Date Area Pit or Grout Inspection by Date Final Inspection by-r v Additional Comments: ❑ Stk 456-6781 ❑ 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 FEE AMOUNT DUE AM UNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASFI S + EH 1324(REV.i/a 57 T7-b�' #70� 0A EH 14-XI