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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J 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. } Job Address OS + City Olt_ Lot Size PM Owner's Name ,1 A/ y Address r-r^r f Phone x611 �7 u61` Address 3 2IV1 �aaq MDJ04 License No. </y��7b Phone Contractor V, TYPE OF WELL/PUMP:. . .,,,,,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER % SD's DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 3� DISPOSAL FLD. PROP. LINE FOUNDATION b� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationes I Dia. of Well Casing X Domestic/Private -❑ Gravel Pack ❑ Tracy - Type of Casing Specifications 4p"49 i F M Public N Other ❑ Delta Depth of Grout Seal JS Type of Grout _ / '/, I I Irrigation is_.Approx. Depth to Eastern ^ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material {Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION Ll DESTRUCTION i I (No septic system permitted if public sewer is I, available within 200 feet.) installation will serve: Residence' 'Commercial'_ Other t Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK ❑ Type/Mfg'4 Capacity " _ No. Compartments PKG. TREATMENT PLT. ❑ , . r _ Method of.Disposal i Distance to nearest: Wei! Foundation `Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS FI Depth j 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 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse 'do, /6f/ �ID /a S7 Signed X.�_._. _ Title:" Date:c� . . i i FO DEPARTrMENT USE ONLY -x M Application Accepted by n ,.4 `�" Date t4 re \-Pit or Grout Inspection by Date Final Inspection by Data / �~ Y d Additional Comments: it ❑ Stk ;466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNt7. INFO r EH 13-24IREY.rNsr �� EH 1428