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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. r Job Address City Lot Size Ply 04 If Owner's Namer �_� / Address 7 dGf.�c%Yr_�-?i1JPhone23 —Contractor /� Address License No/ Phone TYPE OF WELL/PUMP: NEW'WELL ❑ WELL REPLACEMENT F1DESTRUCTION ❑ PUMP INSTALLATION $. SYSTEM REPAIR OTHER 0 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 J�'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public FI Other F] Delta Depth of Grout Seal Type of Grout _ I Irrigation —.Approx. Dep I + 1 Eastern � Surface Seal Installed by Repair Work Done ❑ Type of Pump; H.P. l 7—, State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top 501 s V 1 Depth Filler Material jgelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is. available within 200 feet.) ([Z Installation will serve: Residence_ Commercial_ Other' f V 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 Prop'rty Line ii LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑ Distance to nearest: WellFoundation Pro I rty Line C SEEPAGE PITS I ! Depth Size Number SUMPS LI 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, anc 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 m s call f r all requiV inspections. Complete drawing on arse side. Signed X Date: FOR DEPARTMENT USE ONLY Application Accepted by Date G Area o Pit or Grout Inspecti b Date al Inspect' n IS Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH13-24(REV.1/85) EH 14"26 _ J