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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 4� F i Telephone (209) 466_B781 IPERMIT 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 Regulations of the San Joaquin Local Health District. I Job Address , `F City Lot Size 1 �� ag� ' Owner's Name C, Address T _ Y9 4 Phone ll Contractor's Name .No. Phone TYPE OF WELL/PUMP: 10W WEL, WELL REPLACEMENT DESTRUCTION ❑ r PUMP INSTALLATION C1 SYSTEM REPAI ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES DISPOSAL FLD.,Kg—�+— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL T PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q p pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack .. Tracy Type of Casing , ' Specifications Elr Public F] Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by "'P"l Repair Work Done ❑ Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material {top 501 Depth Filler Material (Below 50') 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— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth , SEPTIC TANK 171Type/Mfg 1 Capacity--------,-- No. Compartments PKG. TREATMENT ALT. L-22Method of Disposal Distance to na arest: Well Foundation Prop rty 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 ❑ f f 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, d r 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 shalot l nworkman's compensre hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to l tion laws of California." t The applicant st call for all required in ctions. Complete drawing on reverse side. t F Signed f 9 f 'tie., Date: F D PARTMENT US 'ONLY Application Accepted by ` Date Q y Area_. 67 E Pit or Grout Inspection by 9 D .t Final Inspection by Date Additional Comments: �yyd- ❑ Stk 466-6781 ❑ Lodi 369-3621 Li 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 i FEE INFO AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. i EH 13-24{REV.10!83) ,. 4j EH 1428 0