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I � APPLICATION FOR PERMIT f� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA LIAR Telephone (209) 466-6781 tt PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AN JO/ QUI LCCA. 4 T (Complete in Triplicate) HEALTH DISTRICT � f 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 Q v/�! .��® '`l' City Lot Size PM Owner's Name ( Address ! r 6 y ►` phone 7/ ! r ` e i ContractoPs`Narhe"10' - cense'No. -�- 3- - --T-Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ V�DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ L-;,----DISTANCE_TO NEAREST- -SEPTIC-TANK_ SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --�. i 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 -a ❑ Irrigation Type of Grout r —J4pprox. pepth El S}�rface Seal Installed by Q Repair Work Done (B�Type of Pump �,4, H.P. Jr1— State Work Done PAA Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if public sewer isInstallation will serve: Residence_ Commercial `_ Other available within 200 feet.) ? a' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:- Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments n PKG, TREATMENT PLT. ❑ a Method of Disposal �. Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size n FILTER BED ❑ Distance•ta nearest: Well Foundation Property Line O� t t ._ SEEPAGE PITS ❑ Depth ,M Size Number l �� r 4❑ - }nearest -Well, Foundation H . t —SDistance to-nearest- _ - P.rgperty Line, DISPOSAL PONDS L33UMP - 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: E em !o an "I certify that in the performance of the work for which this permit is issued, ! shall not ploy y 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,,).shall employ persons subject to workman's compensa- tion laws of California." The applicant ust c 11 for all requi inspections. C plate drawing opi9yerse side.- Signed ide.Signed tle: Date: D , Z 4 - "' _ .L _ FOR_DEPARTMENT_.USE ONLY— - Application Accepted by -- G G/ Date 1 Area Pit or Grout Inspection by Date Final Inspection by L < -�- 1 Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. CASH t EH 1}24 IREV,10/a31 EH 74.28 _ U —3' f L{