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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE�TON 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 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 d _Ornp x u f City ® � Lot Size _ Owner's Name a Address zx` Phone i Contractor's Name cense No. Phone l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMEiNfT ❑ DESTRUCTION ❑ f Pt1JMP'INSTALLATION'^&--'Z � SYSTEM-REPAIR�❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ - DISPOSAL FLD. /PROP. LINE FOUNDATION AGRICULTURE WELL�` OTHER WELL PITS/SUM S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d IndustFial— ""'^"' a pen-Bottom,_}❑ Manteca Dia. of Well Excavatio � Dia. of Well Casing mestic/Private ❑ Gravel Pack E) Tracy Type of Casing,4} Specifications C5 ❑ Public /6%Other z*p-D81ta Depth of GrouSeal _..___ T pe of Grout ❑ Irrigation L Approx. Depth ❑ astern Sxrface Seal Installed by Repair Work Done`^❑ Type of Pum H.P. p` --0I State Work Done i Well Destructions O1 Well Diameter Sealing Material (top 50') SWI IDepth Filler Material (Below 501 TYPE OF,'SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C1 DESTRUCTION ❑ (No septic system permitted if public sewer is Jo available within 200 feet.) OQ lnstallatio will serve: Residence_ Commercial_ Other 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 ( PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ! DISPOSAL PONDS ❑ t 1 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. 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, 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,I shall employ persons subject to workman's compensa_ tion laws of California." a The applicant must call for all required inspections. m late drawing on reverse side. Signed X_ Title: Date: • FOR DEPARTMENT USE ONLY � •�� Application Accepted by DataA Area Pit or Grout Inspection by l Date It -F Final Inspection by ' DatjeF� Additional Comments: ❑ Stk 4663-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8366385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH h EH 14-26 ^] +EH 1324(REV.10/83) 3-J ^+�87 277A A 4 I. � d