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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE00N AVE., STOCKTON, CA 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 Applica made Ordinance No.549 for sewage or No. 1862 for well/Pump and the Rules and Regulations of the San Joaquin made compliance San Joaquin Cou Local Health District. pp1 City f� �& Lot Sizes PM Job Address 00 /'1�e Phone 7s 7 Owner's Name Address r� ti 0 ! D(�yfh/F� License Phone G Contractor's Name No. Q t TYPE OF WELL/PUMP: NEW WELL F7 WELL REPLACEMENT ❑ DESTRUCTION C3 E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE =_ -FOUNDATION.. AGRICULTURE WELL -- OTHER WELL ,----.—,PITS/SUMPS ��` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial , �� El Open Bottom ❑ Manteca Dia. of Well.Excavation ❑ Domestic/Private ` '" ❑ Gravel Pack El Tracy (Type of Casing) Specifications r ❑ Other A t El Delta Depth Depth of Grout Seal " fi Type of Grout ❑ Public ae `:, t ❑ Irrigation _�pprox.'•Depth ❑ Eastern Surface Seal Installed by H P State Work Done Repair Work Done ❑ Type of Purnp Well Destruction ❑ Well Diameter Sealing ter SeMaterial (top 50'1 IVlat Depth Fillererial (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION ❑ DESTRUCT ION ❑ availabllerc sysm wthin 200 feet.) if public sewer is Installation will serve: Residence— Commercial_ Other ti Number of living units: Number of bedrooms L cols Water table depth Character of soil to a depth 3 feet: Capacity t No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: t .,Well Foundation Property Line LEACHING LINE El Mo. & Length of lines ` TotalRlength/size FILTER BED ❑ Distance to nearest: Well Foundafionr ' Property Line SEEPAGE PITS ❑ Depth Size 5 Number SUMPS ❑ Distance to nearest: Well 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. ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the f employ any person in such manner as to become subject to workman's corrJpensation laws of California."Contractors hiring or subcontracting 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 applic must call for all eq 'red inspe ions. Complete drawing on reverse side. .. ' A. Date: [r+ Q Signed Title: FOR DEPARTMENT USE ONLY p ± b 6VDate r'��..�U Area r� Application Accepted y � 1 Date Final Inspection by Date Pit or Grout Inspection by A./ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 623-7104 ❑ Tracy 835-6395 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK W RECEIVED BY DATE jEPMIT•`No. INFO AMOUNT DUE AMOUNT REMITTED CASH p + EH 13-24IF1EV.10/831 ' �o LAb o '1 k� ^� 8 EH 1428 -. ._ ....