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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED , F. ' L '(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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressFS, City of Size �'""_�K PM Owner's Name dress • Phone _ A.4 Contractor's Name License-No.� °� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION CJ SYSTEM REPAIR ❑ ° OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private J❑ Gravel Pack ❑ Tracy Type of Casing Specifications L ❑ Public ❑ Other' _ 1-8 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. # State Work Done Well Destruction ❑ Well Diameter �" r Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Oth'e Number of living units Number o rooms (` �� Character of soil to a depth of 3 feet: Water table depth U {U SEPTIC TANK f Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ �� "�'" i Method of Dis osal Distance to nearest: Well( Foundation Property Line — ) LEACHING LINE ,No;,:& Length of lines_ Total length/size f FILTER BED 171 Distance to nearest: Well Foundation �� Property Line 79) SEEPAGE PITS ..❑ Depth Size_&*T� tftT_ 'fNumber 1 ' SUMPS Distance to nearest: Well /Qo�7" Foundation�_ Property Line 7 O DISPOSAL PONDS ❑ 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. s , 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." . r The applicant must call r all i i pe ns. Complete drawing on reverse side. �Q� �},, a Signed Title: r/F`•^' Date: l� +/ o` FOR DEP RTMENT USE ONLY Application Accepted by L�f Date Area Pit or Grout Inspection by Date Final Inspectionp� Date Additional Comments: �� _ ❑ Stk 466-6781 ❑ Lodi 369-3621 nteca 823-7104 �❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95,201 FEEt w INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. + i EH 13-24(REV.101831 "-- EH 1428 St 10- 1�� 7 �'�1�� L s