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S - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA i 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District, yy Job Address E 0City Lot Size PM Owner's Name J �� l ddress Phone Contractor ddress � 7a`J -tense No. a d Phone TYPE OF WELL/PUMP: U NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �17 , �� SEWER LINES DISPOSAL FLD.W+ PROP. LINE - FOUNDATION AGRICULTURE WELL .OTHER WELL !.y S/ PITS/SUMPS_._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION �f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_�, 41'_ Dia. of Well Casing Domestic/Private Gravel Pack Tracy Type of Casing ,Loyel Specifications 1'l Public ❑ Other n Delta Depth of Grout Seal Z6 Type of Grout i. .. I I Irrigation —,.Approx. Depth { I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I ) DESTRUCTION I 1 INo septic system permitted if public sewer is 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/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line PAYMENT LEACHING LINE ❑ No. & Length of lines Total length/size RECEIVIED FILTER BED ❑ Distance to nearest: Well Foundation Property Line MAY 15 i SEEPAGE PITS I I Depth Size — Number SUMPS Ll Distance to nearest: Well Foundation Property Line LNWkONMEN7AL HE DISPOSAL PONDS o HEALTH ' 1-hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county oWVW r in aws, and rules and regulations of the San Joaquin Local Health Di§trict. 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." The applicant st call for all require r spections. Complete drawing n reverse,/e/,4 e. Signed Xba Title: Date: FOR DEPAR ENT USE ONLY t Application Accepted by Date` Area Pit or Grout Ins tion b -� f�N� Dates d Final Inspection by Date Additional Com s: ❑ Stk 466-6781 ❑ Lodi 369-3621 nteca 823-7104 Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +.EH1321(REV. i n 5) 9.0 C70 'S 3 �/ 1(0 mrd EH tt-28 J