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i APPLICATION FOR PERMIT r ex SAN JOAQUIN LOCAL HEALTH DISTRICT ' Cy 1601 E. HAZEL T ON AVE.,STOCKTON, CA Telephone-d209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDN (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 describedThis application is ` made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Re --of the San Joaquin Local Health District, : t` Job Address 1 l�G�*�i��`� ' " ? City Lot Size }" PM Owner's Name Address Phone i Contractor xae � __Address F License Phone T i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR t?" 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 ❑ Industrial ` ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public. ❑ Other + ❑ Delta Depth of Grout Seal "type of Grout ❑ Irrigation --Approx}Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done .2' Type ofPump-.�r� H.P. � State Work 0 ie p' Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material Meloini"50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ available within 200 feet.) { installation will serve: Residence— Commercibl- Other Number of living units: Number.of,bedrooms Character of soil to-a depth of 3 feet: Y _Water table depth SEPTIC TANK .o ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT"PLT. ❑ r ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ -No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS - ❑ Depth ' Size — Number SUMPS ❑ Distance to nearest: Well Foundation Property-Line - 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 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 compensationl 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 applicant st call for required inspections. Complete drawing on erre side. r Signed X , l�d'�" '�"� Title: Dater e_�, FOR DEPARTMENT USE ONLY r , Application Accepted by Date 'u Area , Pit or Grout Inspection by ry Date Final Inspection by Date.JL—�� Additional Comments: k ❑ 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 r INFO AMOUNT DUE t. 4'�AMOUNT REMITTED 0 H RECEIVED By DATE PERMIT N0." + EN 13-24(FIEV. 5. EH 14-26