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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Ci Lot Size 20o X 2'-1,v PM Owner's Name 91— Address Phone Contractor dress a �55M License Nb.� — Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESI DISPOSAL FLD. PROP. LINE "'FOUNDATION :� " „"'" "^.. AGRICULTURE WELL t' OTHER WELL'PTS/SUMPS INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONSED i Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal k Type of Grout Irrigation e g =�4pprS Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work D no e { Well Destruction 71Well Diameter :��JSealing Material (top ) 4 0 Depth Filler Material [Below') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION ❑ DE TRUCTION (No septic system permitted if public sewer is I NI Installation will'serve: Residence, Commercial Other I `e-- available within 200 feet.) Number of liJg units: Number of bedrooms'. Character of sail to a depth of 3 feet: Water table depth `l , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments " PKG. TREATMENT PLT. ❑ Method of Disposal 7 Distance to nearest: Well Foundation Property Line { f 3 LEACHING LINE rJ No. & Length of lines `" -"'•'� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth e P Size Number SUMPS _.. F-1 Distance--to nearest: Well Foundation---n- - -,•Property Line- 61SPOSALIPONDS ED �` ► t 1 I lihereby 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 awned or licensed agent's signature certifies the following: -1 certify that in the performance of the work for which this permit is issued, I shall not employ anylperson in such manner as to become subject.'to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the.following:^I certify that in the performance o�the work for which this permit is issued,I shall employ persons subject to woikman's compensa tion laws of California." The applicant must callfoall requir d inspections. Complete drawing on reverse side. i r i Sned t r .g Title: • ` Date: FOR DEPARTMENT 3SE ONLY i Application Accepted by ` date ' ' r Area i Pit or Grout'fnspectiori by ---- Date Final Inspection by 1O $ Date Additional Comments: It Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-15385 { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK Yw INFO CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24 WEV."a 5) EH 14-28