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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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. r � PM Job Address City _ Lot Size 9 a Owner's Name Address / Phone ContractdY" C.0 Address .�' 6 r License No.32g .2-2 Phone d bs Y TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A` 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 Type of Casing Specifications ; 17 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout,_. I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. - State Work Done f 6 Well Destruction EJ Well Diameter Sealing Material )top 50'1 _ Depth Filler Material i6elow 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAI /ADDITION I DESTRUCTION 1 (No septic system permitted if public sewer is 11 available within 200 feet.) installation will serve: Residence-,A- Commercial_ Other 1 Number of living units: --J--- Number of edrooms 4 Character of soil to a depth of 3 feet: // Water table depth SEPTIC TANK Type/Mfg Capacity b D No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Di osal Distance to nearest: Well 50 Foundation i_. Property Line LEACHING LINE No. & Length of tines y 17 Notal length/size 0 K2 FILTER BED ❑ Distance to nearest: Well r�d Foundation 10 Property Line s� SEEPAGE PITS f 1 Depth Size /� Number SUMPS Distance to nearest: Well /00 Foundation +! r Property Line `S DISPOSAL PONDS ❑ j 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. j 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 ' California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compensation laws of i "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." 1. - n The applicant must call f a required inspections. Complete drawing on reverse side. Signed 50 Title: Date:FOR DEPARTMENT USE ONLY / G Application Accepted b Date/ % Area 1t Grout Zments: tion by Final Inspection by ate Addit o—a T f LI-St-k- Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH +-EH 13-24 1HEV.r/A 5) ` EH 1429