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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA i o f Telephone (209) 466-678188 z ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUE E� (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. " City-6-1-COM-01 Lot Size PM Job Address Owner's Name Address 1 �d�` Phone Contractor ( I Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION F71SYSTEM REPAIR ❑ OTHER LY Sul �� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C1-`T) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LINE —( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack F] Tracy Type of Casing Specifications I"I Public 17 Other � ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth l I Eastern Surface Seal installed by - 1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 1 Filler Material (Below 501 V E OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system m rented if public sewer is Installation will serve: ��e_� Commercial— �Other Number of living units: Num.ee drooms Character of soil to a depth of 3 feetil_ Water table depth SEPTIC TANK LJType/MfgF - Capacity No. Compartments y PKG. TREATMENT PLT. ❑ , Method of Disposal Distance'to nearest: Well Foundation Property.Line ( Total length/size I l LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line .I SEEPAGE PITS 11 Depth :# Size Number SUMPS ❑ Distance tto nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. 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 theJollowing:"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 la sofCalifornia." + The plican c I for all uir Hsps ti s. Complete drawing on reverse side, _ ow 'i Signed X Title: ` o Date: rfS U FOR DEPART N#ENT fUSE NLY Application Acce ted by YiGf Date ( Pit or Grout Inspection by Dara Final inspection by Dater t Additional Comments: ` l ❑ Stk 466-6781 ❑ Lodi 369 1 El Manteca 823-7104 ❑ Tr y 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 r¢ FEEAMOUNT DUE}} AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. +� �� a-EH 13-24 IREV.t/n 51 INFO - +� `-S—)S EH 14-2e