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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT �'k Lrt• 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 r made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of.the San Joaquin Local Health District. Job Address 9'n 9 r��v ,�C City Lot Size PM � GZG urf7S Jgee-- Phone Q O erltlame ed�Ltrc. yR�1 Address Contractor Address License No. ��—��/ Phone 6 - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ 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 f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F'1 Public ❑ Other F7 Delta Depth of Grout Seal Type of Grout--, I I Irrigation _."Approx. Depth I 1 Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pum .Sir L H.P. 1 State Work Done e p yp p �— � & ?�/-t.- Well Destruction ❑ Well Diameter Sealing Material (top 50') '`� Depth Filler Material l8elow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION F I (No septic system permitted if public sewer is 0 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil'to'a depth of 31666.— Water table depth ["p } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments "V PKG. TREATMENT PLT. ❑ Method of Disposal rDistance to nearest: Well Foundation Property Line cq LEACHING LINE ❑- -No. & Length of lines f Total length/size {y� FILTER BED ❑ Distance to nearest: Well Foundation Property Line T SEEPAGE PITS i I Dept>h" Size _ Number SUMPS Irl Distance to nearest: Well Foundation Property Line 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 Di§trict. Home owner 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 f employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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." k The applicant must call for all re aired inspections. Complete drawing on reverse side. ' Signed X Title: Date: i FOR DEPARTMENT USE ONLY i � Application Accepted by 17 Date>/ Area / i Pit or Grout Inspection by Date Final Inspection by ' Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t.EH 13-24(REV.1/85) r EH 14-28