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:. :• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE.T ON AVE., STOCKTON, CAS Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hoieby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -� }}�, i Job Address G� P/ L -City .n Lot Size - Z__PM J Owner's Name _ Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION &I IONS li ❑ Industrial ❑ Open Bottom ❑ Manteca D' e I Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tra Type of,Casing Specifications ('1 Public Ll Other 1-1 Delta Depth of Grout Seal Type of Grout _. J I I Irrigation _ prox. Depth I 1 Eastern Surface Seal Installed by - Repair Work Do Type of Pump H.P. " State Work Dane_ Well D ction ❑ Well Diameter Sealing Material Stop 50'I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION f.l REPAIR/ADDITION 1.1 DESTRUCTIONY1 Wo septic systempermitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial_ Other. Y IE Number of living units: Number of bedrooms Character of soil to a depth of 3 feet' Water table depth C� SEPTIC TANK (71 Type/Mfg -Capacity No. Compartments PKG. TREATMENT PLT. ❑ �. :. _ Method.of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSI I Depth ,- Size !Number -SUMPS Ll Distance,to nearest: Well Foundation Property-Line 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. E 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 r employ any person in such manner as to become subject to workman's compensation 16ws 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,1 shall employ persons subject to workman's compensa- tion laws of California." i The applicant must EM for all required ins ction omplete drawing on reverse side. Signed X Title: Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by v b Date Area ` ` Date Final Inspection b Date 0�_ Pit or Grout Inspection by -- p Y r' Additional Comments: �� [ �� "✓ �� " `/�� -- ❑ Stk 466-6761 ❑ Lodi 369-3621 © Manteca 623-7104 racy 83S-6385 A pI' ant- Return all copies to: Environmental Health Permit/Services 160 zelton Ave., P.O. Box 2009, Stk., CA 9 0 FEE INFO AMOUNT DUE AMOUNT REMITTED COASH RECEIVED BY GATE PERMIT'NO. 1 - � d t EH 13.24 IREV,i i H sl t3 �� S1/0 EH 14-28 f