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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 RA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Oft/ �q (Complete.in Triplicate) EgLJOlgQtl ; Ply Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des ma de is made in compliance with San Joaquin County Ordinance No.549 for sewage or-No. 1862 for well/pump and the Rules and Regulations Joaquin Local Health District. ��Jab Address City Lot Size PM r Owner's Name Address'�?l 1' /�/ '�' -- Phone a t Contractor's Name `^ License No. Phone TYPE OF WELL/PUMP: NEW;WELL ❑ WELL REPLACEMENT El DESTRUCTION ED PUMP INSTALLATION ❑ SYSTEM REPAIR GK OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESj_ DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL--- -YOT.HER 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 ❑ Gravel Pack ,. ,❑ Tracy Typeiof Casing Specifications ❑ Public El Delta ..D-ept1 of 3rout- S641 - Type of Grout I ❑ Irrigation ---Approx. De ❑ Eastern Surface Seal Installed by vC, Repair Work Done ❑ Type of Pumper H.P. Z0 0 State Work Done Q Well Destruction ❑ Well Diameter 1 Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-El DESTRUCTION ❑ (No septic system permitted if public sewer is ,.I- i available within 200 feet.l Installation will serve: Residence_ Commercial_ Other t r Number of living units: Number of bedrooms i (I Water table depth 1 y Character of soil to a depth of 3 feet: _ P SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. r-: Method of Disposal ..,.. _ Distance-to-nearests-_Well— Foundation---=-=—Property-L•ine -�--� F� LEACHING LINE ❑ No. & Length of lines { Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i � r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y' s DISPOSAL PONDS ❑ k 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.ih is permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." { f r ,f` The applican st c for all r inspection Complete drawing on reverse side. Signed Xtl�: Date: T FOR DE RTMENT•USE ONLY ' Application Accepted by Date ` ! Area Pit or Grout Inspection by Date I Final Inspection by Date i Additional Comments: i ❑ Stk 466-Ml ❑ Lodi 3&9-3621 ❑ Manteca 823-71d4`. ` I ❑ Tracy 835-6395 j Applicant- Return all copies to: Environmental Health Permit/Services'160T'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO III r EH 13-24 IREV.19/e31 EH 14-28