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4 sP APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i. '1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,It (Complete in Triplicate) tl 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'Ncr. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address City `�" '" Lot Size S�r"a PM - O Phone b' g Owner's Name X10 M�n'�"``j��— Address r Contractolr 5�- -- Address License No. Phone TYPE OF WELL/PUMP: ANEW WELL 7_1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 C ❑ Industrial ❑.Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing [ ❑ Dome.1 O Gravel Pack. ❑ Tracy Type of Casing Specifications f ti Type of Grout F1 Public C1 Other Cl Delta Depth of Grout Seal YP I 1 Irrigation �.'Approx. Depth 1 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type,of Pump _ H.P. State Work Done 4 ` Sealing Material ito 50'i Well Destruction ❑ Well Diameter g p Depth I Filler Material iBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTION iNo septic system permitted if public sewer is available within 200 feet.I \ i Residenceon wilt serve: ._Commercial_ Other Installati \ l Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line I. LEACHING LINE ❑ No. &'.Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size_ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ifr 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 Di§irict. Home owner or licensed agent's signature certifies the following: "! 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 wprkman'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 re wired inspections. Complete drawing on reverse side. Signed" Title: Date: S FOR DEPARTMENT USE ONLY r :p t Application Accepted by tlti Date �q Area z Pit or Grout Inspection by Date Final Inspection by Date Additional Commentst!" � ' 11Stk 466-6761 ❑ Lod'i 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385 =, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. FEE +.EH13-24 1flEV.t/n51 EH 14-26 �� ,. q