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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA E Telephone (209)A66=6;4�— �3 �� 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. t Job Address City Lot Size PM Owner's Name MW5 Address /i /`- 'Y - Phone / Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION PUMP INSTA LLA SYSTEM REPAIR CI 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LlGravel Pack C1 Tracy Type of Casing Specifications ❑ Public Cl Other P Delta Depth of Grout Seal Type of Grout — I ( Irrigation Approx`. Depth l 1 Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump _ H.P. State Wor Done Well Destruction Well Diameter Sealing Material (top 501 �l Depth c'�l i Filler Material (Below 501 PE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION i I (Nos Attic system permitted if publ' sewer is availaInstall ' n will serve: Residence_ Commercial— Other Number of i i g units: Number of bedrooms Character of soil depth of 3 feet: Water depth SEPTIC TANK Type/Mfg Capacity o. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal Distance'to rest: Well Fou n Property.Line SI LEACHING LINE ❑ NO. & Length of lines Total length/size FILTER BED; ❑ Distance to n Well Foundation Property Line r t i SEEPAGE PITS ('1 epth . I -Size mbef i I SUMPS Ll Distance to nearest: Well Foundation Pro Line i DISP 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 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 ust call for all r ire in tions. Complete drawing on reverse side. r Mme, Title: — Date. Signed X - , FOR DEPARTMENT USE ONLY /�� Application Accepted by Datehih6A a -'-�� Pit or Grout Inspection by Final Inspection by Date 4 Additional Comments: © Stk 466-6761 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-0. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24{REV.r/k 51 I EH 14-28