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APPLICATION FOR PERMIT r. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone 12091 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 tf City Lot Size PM �y� 1 Owners Name Z .2/5VdAddress- '!:7tW Phone f X Contractor's Name / License No. Phone TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONS- SYSTEM REPAIR.Rk, 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- 0 PECIFICATIONS_❑ Industrial s V Open Bottom ❑ Manteca �FDia. of Well Excavation Dia. of Well Casing k ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation _-4pprpx.'Depf�F--M Eastern" "` '�"°�S6rface Seal Installed by Repair Work Done A . Type of Pump Xc+�/ H.P. f! State Work Done r- \ Well Destruction ElWell Diameter Sealing Materia! (top 50'1 Depth { Filler Material (Below 501 f TYPE OF SEPTIC WORK:' NEW INSTALLATION ❑ REPAIR/ADDITIONJI DESTRUCTION ❑ (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 , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 y' ' SEEPAGE PITS ❑ Depth Size Number SUMPS f ❑ Distance to nearest: Well Foundation Property Line ► DISPOSAL PONDS p 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. s 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 ins anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: I c 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 Californ' .' The applicant mu II requ' d tions. Complete drawing on revers Signed Title: `� ' y Date: _3 f " FOR DEPARTMENT USE ONLY fI x Application Accepted by �L ��51 Date �Cl _ r Area i Pit or Grout Inspection by Date Final Inspection by Dat j��* Additional Comments: i Dptk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca 823-7104 II Tracy 835-6385 licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA%W1 tP INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"ND. II�. + PH 1}2q(REV.10/831 EH 1426 INFO ! !! d Ui�