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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT FILE 1601 E. HAZELTON ON AVE., STOCKTON, CA con 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. _ . Joh Address I qt)() �� Cit Lot Size PM Owner's Name Address Phone ContracE r & Address License No 2 '2 Phone o –S t o 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 C1Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Speck,; elons ❑ Domestic/Private El Gravel Pack ED Tracy Type of Casing �_ l l Public ❑ Other El Delta Depth of Grout Seal Typ of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR ADDITION DESTRUCTION l i (No septic system permitted if public sewer is - � r vajlable within 200 feet.) Installation will serve: Residence_ Commercial Othe Number of living units: Number f bedroo s f Character of soil to a depth of 3 feet: Water table depth O I SEPTIC TANK ❑ Type/Mfg Capacity , sA a No. Compartments a 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 L / 1 SEEPAGE PITS Depth Size --� t�lumber SUMPS Cl Distance to nearest: Well _ Fouridation -+ Property Line DISPOSAL PONDS ❑ hereby ceiiify 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, I shall employ persons subject to workman's compensa tion laws of California." The applicant mINAlcall for all uir d inspections. Complete drawing on reverse e. _ Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOEDUE AMOUNT REMITTED CASH ' RECEIVED BY DATE PERMIT'NO. «.EH 13-24 IREV,t r H 51 ! +� '�� EH 1426 [ I4 I! Ej 1 r