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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) -Application is hereby made to; he 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. 1 �ii / i Job Address City Lot Size �3� PM 4� [ Owner's Name A'� Volk Address �` � 75� _ Phone +L—w-+ Contractor t Address�� _IJ„I ti j;5N License No. Phone'! ✓ TYPE OF WELL PUMP: N�i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: S PTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION. -,AGRICULTURE WELL,. .OTHER WELL PITS/SUMPS INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ` ❑ Industrial 0Open Bottom ❑ Manteca ' Dia.`of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑(Gravel Pack C1-Tracy . ' .Type of-Casing Specifications t. l f'1 Public f 7l4ther ❑ Delta ` Depth of Grout Seal Type of Grout 11 Irrigation _Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done x Well Destruction ❑ Wglil Diameter .�` Sealing”Material {top 501 Depth - Filler Material (Below 50') TYPE OF SEPTIC WORK: N`EW INSTALLATION 1.1 REPAIR/ADDITION 11 DESTRUCTION [No septic system permitted if public sewer is II available within 200 feet.] Installation will serve: Residence_ Commercial_'Other } Number of living units: 'I. Number of bedrooms _ Character of soil to a dept' of 3 feet: Water table•depklt x SEPTIC TANK * ❑ Type/Mfg Capacity 'No. Compartments I r PKG. TREATMENT-PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ I No. & Length of lines Total length/size _ I FILTER BED ❑ . Distance to nearest: Well Foundation Property Line I, SEEPAGE PITS l-I i Depth Size Number SUMPS Cl'I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C7 LI i y 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 i rules and regulations of the San Joaquin Local Health District. Home owner or licensed ager%t's signature certifies the following: "1 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 certihy that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." .III The applicant st call for I required ins ctions. Complete drawing on reverse.side. Signed X Title: 1/1 Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date r Area t� Pit or Grout Inspection b I�, Date Final inspection by Date b a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36b-3621 ❑ Manteca 3-7104; ❑ Tracy• Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r EH13-24(REV.1/H 5) !� U ( � � EH t4-26