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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI`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. ft..:, Job Address �(�` .- ^� .� { `" City •r V Lot Size PM Owner's Name _i5�e t A' J Address f Phone - Contractor Al Address / ►�e 2 License No, /72 _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic(Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r 1 Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUC_TI (No septic.system permitted if public sewer is I r available within 200 feet.) installation will serve: Residence_ Commercial_ Other t I ! M Number oflivingunits: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANKL ❑ Type/Mfg Capacity Nof Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal �� ' I Distance to nearest: Well Foundation Property Line , k LEACHING LINE ❑ No. & Length of lines-°'.•°'. -72t Total length/size t FILTER BED ❑ Distance to nearest: ,<,Well 1 t Foundation Property Line SEEPAGE PITS ❑ Depth Size " Number ' SUMPS 0 Distance to nearest'.ti. Well Foundation- ---4-Property- ine ' 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 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contiactor 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." The applicant must call for reguiped inspections. Complete drawing on reverse side. g Signed Xs Title:_ Date: �� 7 F DEPARTMENT USE ONLY oc-� sa Application Accepted byrC�'w+ r.� Date 'r '� Area t Pit or Grout Inspection by Date - Final Inspection by Date +� I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ;❑ Tracy 835-6385 € i Applicant- Return all copies to: Environmental Health Permit/Services 1601 iE. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I r INF AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH13-Z4iREV.t/H51 � �f JJ_s EH 1426 If llJJ