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' APPLICATION FOR PERMIT SAN JOAQUIN. LOCAL HEALTH DISTRICT 1601 E.-HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED •,,:;x;3t' (Complete in Triplicate)- Aj plication 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. Y" 416-41 Job Address Owner's Name �S If/��Address Phone 6 f'5- 3�x Phon Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 ( T e ❑ Public' El Other ❑ 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 Sealing Material Itop 501 411 ---Depth —Filler-Material.(Beiow-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:TResidence Commercial '_:,,Other. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth e O SEPTIC TANK ❑ Type/Mfg T Capacity NoCompartments . IN PKG. TREATMENT PLT. L Method of Disposal Distance to nearest:i'Well t Foundation W4 Property Line (P rj = . tsize LEACHING LINE ; No. & Length of lines r°Toofal length/ T, FILTER BED ❑` Distance to nearest: Well Foundation –. f Property Line ( SEEPAGE PITS- s"' O Depth Size _ . umber SUMPS ! : Distance to nearest W ell'- Foundation f Property Line s f _ DISPOSAL PONDS {aI�herbby.certify;tKat•I 66vb-piepa-red this ication and that the work w II be done in accordance with San Joaquin county ordinances,state laws, and rules d regulations of the San Joaquin Local Health-DM:ict. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of 5the 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,1 shad employ persons subject to workman's compensa- tion laws of California." 1 The ap t must c tl for alt requ'ed inspections. Complete,drawing on reverse side. Signed X_ Title: � 51 — Date: r FOR DEPARTMENT USE ONLY , -- 1 , Application Accepted by r^' Date r Area Pit or Grout inspection by J Date Final Inspection by Date- .-- r Additional Comments: " ❑ Stk'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 FEE AMOUNT OUE� AMOUNT REMITTEib CA RECEIVED BY DATE PERMIT'NO. INFO +EH 13-24 IREV.10/83) QEj, F •7' - — ��'� S EH 14-26