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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL T ON AVE., STOCKTON, CA \ r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 6 1 f6 0 f` I^4151el City Lot Size PM V Owner's Name 1eAWVAddress �� `� �'��`f_ �� Phone -1 Contractor_ �7 Address �i� License No. Phone a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE z'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial " ❑ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private. ❑ Gravel Pack Ll Tracy Type of Casing Specifications R M Public ❑ Other Ll Delta Depth of Grout Seal Type'of Grout _ I I Irrigation _..Approx. Depth I Eastern Surface Seal Installed by C i Repair Work Done ❑ Type of Pump H.P. State Work Done? ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION i>QNo septic system permitted if public sewer is 0eilable within 200 feet.) , } Installation will serve: Residence Commercial Other i Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: "" '" ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ " r Method of Disposal Distance to nearest: well � Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size " FILTER BED EI Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS 11 Depth Size Number - i SUMPS ❑ Distance to nearest: WC41 Foundation Property Line DISPOSAL PONDS ❑ r P 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 1 rules and regulations of the San Joaquin Local Health District.. 4 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, 1 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 mu allfor all required inspections. Complete drawing on reverse side. >( Signed '�//� Title: Date: „ y !!x—f`� FOR DEPARTMENT USE ONLY i Application Accepted by Data � � O Area �� Pit or Grout Inspection by Date Final Inspection by �i Additional Comments: ❑ Stk .466-6781 L Aodi 369-3621 ED Manteca 823-7104 LJ Tracy 835-6385 { i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Boz 2009, Stk., CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. O r +•EH 13-24 IREV.i/n 5) 4 4 SS EH 14-26