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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 r �^ City I Lot Size PM jt Za Owner's Name j Address Phone f F y O�� _ Phone �r Contractor's-Name License No. I�: ' TYPE OF WELL/PUMP: NEW WELL;*� WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ID SYSTEM REPAIR ❑ OTHER 171DISTANCE TO NEAREST: SEPTIC TANK dao '- SEWER LINES DISPOSAL FLO./cW/+PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLS PITS/SUMPS r I' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r! ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavationyy,, Dia. of Well Casing X Domestic/Private X Gravel Pack El Tracy Type of Casing �Y�� Specifications ,I' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout, r O ❑ 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 (top 501 [ II VE Depth i Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceJ 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. ❑ I Method of Disposal D Distance to nearest: Well Foundation Property Line �y r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance rto nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth I Size Number SUMPS D Distance to nearest: Well Foundation. Property Line - DISPOSAL PONDS" ❑ 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant• call for ell required in tions. Complet drawing on re rse si e. r f :: ti-w Signed itie: Date: i. 2EPAIRTMTMENT SE ONLY Application Acceptedby r'. Date t , `!`� �� Area a9 e glom lV� Date Pit or Grout.lnspection by ate Final Inspection by * a Additional Comments' ♦7f ❑ Stk 46Fi•fi781 ❑ Ladi 369-3621 Manteca 823-7104 ❑ Tracy 835`6385 Applicant- Re� t�urhall copies-to: Envir6inmental H Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NtrO." +EH M241REV.10/831 �.3 • ��",�Sp 6p_s/ ss p� EH 1426