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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '('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 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. Job Address Citv Lot Size Q� �+� PM � �-, GF�f s � Phone f Owner's Name ddress Contractor Address S 0 License No � / Phoneg 3 TYPE OF WELL/ UMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES ' �� DISPOSAL FLD. PROP. LINE ' I—FOUNtATION'"""'-"-"""""'`AGRICULTURE WELL"+-� ,,OTHER-WELL -PITSGSU'MPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s "'� - Dia. of Well Casin ❑ Industrial { El Bottom ❑ Manteca Dia. of Well Excavation I9 p' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public n Other n Delta Depth of Grout Seal Type of Grout (\ I ] Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 ETYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 I DESTRUCTION (Na septic system permitted if public sewer is !i ( vai y le ;thin 200 feet.) Installation will serve: Residence— Commercial_ Other f "` t E 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 r PKG. TREATMENT PLT. ❑ }Method of Disposal j Distance to nearest: Well Foundation PropeAy Line LEACHING LINE g ❑ No. & Length of lines ToZII,' thlsize FILTER BED ❑ Distance to nearest: Well Foundation roperty Line SEEPAGE PITS I i Depth Size Number 'f SUMPS Ll Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ r I I hereby certify thrat I have prepared this application and that the work will be done in accordance w%Mth San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f Home owner or licensed agent's signature certifies-the following:._;certify that•in-the'-performance-of the work for which this permit is issued, I shall not F employ any person in such manner as to become subject to workman's compensationt,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 subi6et to workman's compensa- tion laws of California." The applicant mus all for al a ins tions. Complete drawing on reverse side. Signed X } Title: 1l/�-e'�`�-t/L _ Date:; � �`� - - f I �- 7 "" !FOR DEPARTMENT USE-ONLYApplication Accepted-by r �_..-..- -----------------.__pat — Area p p Pit or Grout Inspection b Date Final Inspection by / Date 0 Q Additional Comments: f U " + 0 I+ Le 0 h T © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 4823-7104 ❑ 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 REMITTED CK H RECEIVED BY DATE PERMIT NO. INFO �f �p t EH 13-241REV.1/n5l EH i4-2a --dam illift.r