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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE TION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 3 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 W9ob io W City Lot Size PM Owner's Name 2 Address I—SA046 /rS r:j a�l' Phone 360ch Contracla&XI C Address Lq'(o� IT ll fl rJ�Ii "erase No Phone3� 13 TYPE OF WEL !PUMP: ) NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ItMomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public f f Other {-1 Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. Depth i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done T+ Well Destruction ❑ Well Diameter Sealing Material (top 50'1' IF Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION I I DESTRUCTION E I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms rt} Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not I employ any person in such manner as 10 become subject to workman's compensation laws of California."Contractors 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 must call all required inspections. Complete drawing reverse side. f� i Signed X Title: Date: 0 ` 7 FO EPARTMFh USE ONLY Application Accepted by Date Pit Area Pit or Grout Inspection by Date Final Inspection by _1 � Da { 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 95201FEECK i I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. r +.EH 13-24(REV.r/n TO r EH 14-26 / )--9