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APPLICATION FOR PERMIT w #" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . , i t * # ,..: : r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED2- f (Complete in Triplicate) : �er~i : ..,•, ,- -, 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 ✓ 1 " City Lot Size PM Owner's Name 46 Address � { Phone7. Contractor's Name 7"ABV License No. r�fL Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ as PUMP INSTALLATI SYSTEM REPAIR, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES TV DISPOSAL FLD. PROP. LINE 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.:Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump- s H.P. l 14 - State Work Done Well Destruction ❑ . Well diameter Sealing Material (top 50')F N Depth Filler Material (Below 50'1 — J ? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,t z available within 200 feet.) Installation will serve: Residence— Commercial_ Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: [ Water table depth SEPTIC TANK ❑ Type/MfgCapacity •---�--'"No'Cori_partmerits- PKG. TREATMENT PLT. ❑ i{ 1 Method'of Disposal's i Distance to nearest: Well Foundations± Property Line ' LEACHING LINE ❑ No. & Length of lines = } Total length/.size' FILTER BED ❑ Distance td nearest: Well FoundationProperty Line t SEEPAGE PITS 11Depth Size .Number- SUMPS ❑ "Distance to nearest:` Well Foundation R Property Line DISPOSAL PONDS ❑ "1 hereby certify that I have prepared this application and that the work will be done:in accordal4e_-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 W6 performance of the work for which this permit is issued,.l shad 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,J.shall-employ"persons-subject to workman's compensa- tion laws of California." k The applican ust ca for all r quire in ctions. Complete drawing on reve se side. f� Title: l � &e5. Date: Signed ^ R DEPARTMENT USE ONLY Application Accepted by. Date 2 _ Area -- Pit or Grout.Inspection by Date Final Inspection by AL DategS Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621" 0 Manteca 823-7104 ❑"Tracy 835-6385 r Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ffEAMOUNT DUE y AMOUNT REMITTED CASHRECEIVED BYDATE PERMIT"NO:EH 1324(REV.10!93) /1-7A-f . EH 1428 fr