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APPLICATION FOR PERMIT 1 SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES) YEAR FROM DATE ISSUED !,(Complete in Triplicate) f? 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. Y A f �Y Lot T. PM Z�S�O-W AQ V City.. 1�C. Size Job Address , , t - -, ♦,,S t/[J Address Phone J 712; Owner's Name �.� �f(' Contractor {! Address l� L Wp r� License No,�� 3" Phone33 Y7 Z TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION . SYSTEM REP10R ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 10 0 SEWER LINES, - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Isa ISS! rsr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing IN-DomesticlPrivate Gravel Pack Type of Casing YC Specifications `p co-,"ElPublic �[4❑ Other ❑ Delta Depth of Grout Seal Z Type of Grout C/V k ❑ Irrigation PRrox. Depth astern SYrface Seal.Installed by O� IIII Repair Work Done EI Type of Pump �LJ H.P. Z'"�L State Work Done } � Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �� 1 Filler Material {Below 50'1 /"�C-= Depth = TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system m f fitted if public sewer is available 3 - Installation will serve:—Residence-- ..Commercial— Other r Number o living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg'. Capacity No. Compartments r PKG. TREATMENT PLT. F-1Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER'BED^ ❑ Distance to nearest: - well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ -Distance to nearest: �.� Well Foundation Property Line DISPOSAL PONDS Cl < ! 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 f 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.''"""`y ; The appiicant must call forall re uired inspections. Complete drawing on reverse side. oy Signed:C -,� Title: Date:Z Q- r FOR DEPARTMENT USE ONLY Application Accepted by Date �� -- Pit or Grout Inspection b � c -Date Final Inspection by Date _ z� I Additional Comments:-- M ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITD CASH RECEIVED BY DATE PERMIT NO. TE INFO + EH 13-24(REV.1. 5) EH 1428