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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. ti Job Address City Lot Size PM Owner's Name Address Phone P � r Contractof ess ! fia:4:�_ License No! i'SC T Phone TYPE OF WELL/PUMP: IV NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEt 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other '� ❑ Delta Depth of Grout Seal Type of Grout ._ I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ >` Well Destruction ❑ Well Diameter Sealing Material atop 50'I Filler Material (Below 501 TYPE OF SEPTIC WORI. NEW IN ALLATION ("I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is ._ available within 200 feed Installation will serve: ce_ Commercial _ Other t Number of living units: Number of bedrooms„ "U Character of sail to a depth of-3 feet- Water table depth SEPTIC TANK ❑ Type/Mfg Q Capacity 2-00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well 14 V Foundation /D - Property Line .-3 6 LEACHING LINE ❑ No. & Length of linesTota! length/size 160, FILTER BED ❑ Distance to nearest: Well Ivo_ Foundation -.1 Property Line 1 SEEPAGE PITS I 1 Depth Size t Number 01 SUMPS L] Distance to nea st: Well /.T Foundation ,..fZn 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, ano-, . 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The appiicant ust call for all quiredins ctions. Complete drawing on reverse side. r Signed X Title: Qt:d Y_sl— - Date: FOR DEPARTMENT USE ONLY f J� Application Accepted by pate% ~� �/ Area f or Grout Inspection by Datez-1zim Final Inspection vAdditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permlerrrices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Vkl FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. INFO } CASH �j /� + EH 13-24(f1 EV.1/H 5) // � �S��JY X��?s EH 14-28 L/ !/ 6