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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 1 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 4ocal Health District. "Z) .Job Address I � Vv 2-G City (to of Size PM Qwner's Name tr r 'a r "' I �OJrless i� M L t Phone 93 / 0 .Cgntractor's Name —a—A Lice iJ / �4 T_ Phone 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL LATI ! SYSTEM REPAIR ❑ OTHER ❑ C� DISTANCE TO NEAREST: SEPTIC TANK J FOUNDATION GRICULTURE WELL OTHER�WELL/= 'PITS/SUMPS INTENDED USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFICMOl15JL ❑ Industrial pen Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing ❑ Do tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S Specifications S?Iublic ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by G ✓� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well DiaTeter Sealing Material (top 50') Depth' ' Filler Material (Below 501h t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ .(No septic system permitted if public sewer is �J` 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/MfgCfapacity ' No. Compartments PKG. TREATMENT PLT. El � -'Method of Disposal Distance to nearest: Well Fpundation`, Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation. Property Line ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and'that the work.bvill be done it1'ac6ordance 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." Contractors hiring or sub-contracting signature certifies the following:"I certi thJ' he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- PAtion laws of Cal'ornia."The applican s call r II qn pe i C mple drawing on rev s s e. »_ Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate Area 1 Pito Grout spection by ate final Inspection by Date Additional Comments: _ ❑ Stk 466-6781 O Lodi 369421'. C`] Manteca '8_2A-7104 - O 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 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY h DATE PERMIT NO. i 13-24(REV. EH 1426 10/83) Li T'� LS