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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. 18622 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.._. Job Address 1 City �� Lot Size "j5M Owner's Name Addresse1• Phone 0 Contractor '? Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications ❑ Public . , ❑ Other I ❑ Delta -k Depth of Grout Seal a 1 �e��.. � p Type of Grout ❑ Irrigation r .- - Approx.'Depth ❑ Eastern "' Surface Seal Installed by I ° Repair Work Done ❑ Type of Pump="' H.P. State Work Done Well Destruction-' i❑ Well Diameter. ` Sealing Material (top 50'1 Depth r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑_ DESTRUCTION El (No septic system permitted if public sewer is . • - , available within 200 feet.l Installation will serve: Residence� Commercial— Other L Number of living units: ,Number of bedrooms I ` £ {. Character of soil to a depth of 3 feet: ' I r414 Water-lable depth SEPTIC.TANK ❑ -'Type/Mfg; Capacity�0-� No:Compa rents•-- I PKG. TREATMENT PLT. ❑ i ,+ �� . Method of Disposal � Distance�to nearest: Well Foundation—Ja Property Line LEACHING LINE s1V6. ,Length of lines zoo Total length/size FILTER BED El Distance to nearest: Well _ Foundation tea_— Property Line SEEPAGE PITS [>) Depth Size Number SUMPS ❑ Distance to'nearest: Well /2C)—J � Foundation�r�Q_._ Property Line 7�� _• � DISPOSAL PONDS ❑ '� "t ; 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. - %61 `,I 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." t The applicant mu c II r all r u d inspections. Complete drawing on reverse side. Signed ` - 'Title:, qtr Date: l � FOR DEPARTMENT USE ONLY Q lication Accepted by ` Date L s^ U ea C)4 Pit Grout Inspection b =� '�� Pe Date Final Inspection by_C a Additional Comments: ❑ Stk 466-6781 0,Lodi 369-36215 ❑ Manteca 823-7104 ❑ Tracy 6355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F 4 - L FEE AMOUNT DUE _ AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO + EN 13-24(REV.i/a sl �� p� EH 14Za _ _ �! 1�� j k.^to 5 L .