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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE LTON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 ' PERMIT EXPIRES 4'YEAR FROM DATE ISSUED (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit t 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. M416� Job Address -14�7rr _5-_ &Z02_ City r' Lot Size PM. Owner's Name 5v--,Address D _ Phone Contractor 922 Address cJ License No, Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE F FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F� Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation _--Approx, Depth l I Eastern Surface Seal Installad by Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material )top 501 ^� Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: ResidenceCommercial_ 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. ❑ u Method of Disposal Distance to nearest: Well Foundation Property Line i J LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Wel! Foundation Property Line 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. 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 must II (pr all req�i inspections. Complete drawing on reverse'side. Signed X - Title: —__- Date: 145, FOR DEPARTMENT USE ONLY 9 - Application b ° / pP Accepted p Y � � Date Area, Pitor Grout Inspection by 'Date Final Inspection !' I[ Additional Comments: ❑ Silk 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 +' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERMIT'NO. f +.EH13-241REV, E14-26 i/ASf 35 3� ��` l'� 3 O y p�p�IGW H