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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 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. �c � Job Address S� C ��u '�`—e) 6t-� City ot Size PM Owner's Name /r"k/) 4144,� 4;4Address 9 7 Phone r_1 /V ContractorAddress 5— —A License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 1`I Public r Other Cl Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Baiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONJA DESTRUCTION l I (No septic system permitted if public sewer is / yav le within 200 feet.) Installation will serve: Residence Commercial_ Other _ Number of living units: Number of hadmorrys,� ,6 Character of soil to a depth of 3 feet: �► Water table depth SEPTIC TANK L1Type/Mfg Capacity �2 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines �otal length/size FILTER BED ❑ Distance to nearest: Well Foundation �g Property fine 776L- SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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' such manner as to become subject,to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f.1. : "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 Califor ia." The applicant t call for Irons. Complete drawing on-re erse side. SignedX Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _-_ Date Area Pit or Grout Inspection by ate Final Inspection b a Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Mantaca 62 -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 INFO AMOUNfTbi�UE AMdUNT REMI REGEI ED 9Y DATE PERMIT'NO. EH 1324)HEV.r i H sl —7404 ��V ;7&/�. fA9 ' EH 14-2e