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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. APP Lot Size PMS Job Address S /7f City 14 IeCS G6�S Address �' S }�J T _ Phone Owner's Name : Contractor. . A-jej/ GG 2. -Address ?�� .License_Na.- 5 � Phone_ _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIrC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial fl Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j FPublic Cl Other ❑ Delta Depth of Grout Seal Type of Grout I t Irrigation —.-Approx. Depth l 1 Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P. State Work Done ? Vdell Destruction ❑ Well Diameter Sealing Malarial Stop 501 t r- –Depth I - Filler Material (Below 50') � r T IPF OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence. -Commercial Other I Number of living units: Number of bedrooms �. Character of soil to a depth of 3 feet: _ J`��✓ar/ APD Iii Water table depth # S PTIC TANK a ❑ .Type/Mfg Capacity No. Compartments # PKG. TREATMENT PLT. ❑. - Method of Disposal i'Distance-to nearest: We'll Foundation Property Line ! 42 t`Lf ACHING LINE s` 0 No'.'& Length-of,lines' q C) L Total Iength ize r FILTER BED )d -Distance to-nearest: Well Foundation -212�� Property Line SE EPAGE PITS i I =Deptti`t Size Number SL MPS Ll Distan74 to-nearest;_-'""Well Foundation Property Line ( 'DI POSAL PONDS ❑ •. ' r It ereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ru s and regulations of the San Joaquin Local Health District. H me owner or licensedagent's signature certifies the following: r'I certify that in the performance of the work for which this permit is issued, I shall not an ploy any person in such manner as to.become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ce rifids 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- e do laws of California." i ' The applicant must call for *required inspectiortis. Complete drawing on reverse side. Si ned XTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by �'___ Date Area Pit or Grout Inspection by I Date 11 /� Final Inspection by I Date Additional Comments: F -I vi, > ❑ 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. Bax 2009, Stk., CA 95201 j FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE CK PERMIT'N0. ° i INFO F:A +.EH 13-24(REV.I/R5) - ;� �I 1_ r'Nt EH 1426