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5 APPLICATION FOR PERMIT Rl E RI u It SAN JOAQUIN LOCAL HEALTH DISTRICT !! , - AUG 29 �M 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENViRONMEN i AL HEALTH PERMIT EXPIRES 1'YEAR FROM DATE ISSUED PERM!T/SERVICES V' (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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin .j Local Health District. 1 Job Address City Lot Size PM E Owner's Name Address Phone 42A�L Contractor VAddress icense No. Phone TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION EI1 -0. PUMP INSTALLATION ❑ SYSTEM REPAIR�( OTHER ❑ t i _ l / I` DISTANCE TO-NEAfiEST: SEPTIC TANK SEWER.LINES 4- - DISPOSAL_FLD. PROP. LINE jl FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS it INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! F ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia.of Well Excavation Dia. of Welli Casing -11Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work bone Well Destruction ❑ Well Diameter —S—ea—ling Material (top 50') it Depth � Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION 1 1 {No septic system permitted if public sewer is I available within 200 feet.) Installation will serve:, Residence_ Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK — ____❑.Type/Mfg Capacity ice,. No. Compartments t PKG'TREATMENT PLT. ❑ f \Method,of Disposal Distance to nearest: Well Foundation Property Line I k Ei LEACHING LINE ❑ No)& Length of lines /� Total length/size � r i FILTER BED 'rt. El Dist' to nearest: Well Foundation Property Line r SEEPAGE PITS �* 11 Depth Size _ Number •- ` r SUM SPS • L� DI`stance_to nearest:. Welper l Foundation Property Line Y - ..� DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and tfiat the work will be done in accordance with San Joaquin county ordinances, state laws, and 11 rules and regulations of the San Joaquin Local Health,District. - Home owner or lice ed 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 per n in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signat certifies the fol win : "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa i tion laws of C if ia." x The applic t' t call for all requir d inspection . omplete drawing onVvse. Signed X I Title: Date: OR OEPARTMEN USE ONLY 2 �� Application Accepted by Date Area Pit or Grout Inspection by Da i! Final Inspection by Date Additional-Comments:---- ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O.-,Box 2009, Stk., CA 95201 ij % i" FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' ♦ EH 13-24(REV.1IKS) �` `{ EN 14-28• l b