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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 4 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. Job Address ,f 1 i `�� __ City �• Lot Size PM �E Owner's Name Stu r 8if Address ; Phone ?ETYPContractor It,)A-Lkd V4 I i Address 8 0 LAI CLA4fiwLicense No. z Phone '?E- TYPE E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ »+ DISTANCE.TONEAREST:..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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Y Filler-Material (Below.50' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R rdence_ Commercial_ Other r Number of living units: Number of bed oms Character of soil to a depth of 3feet: .. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity s No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 4.4/Depth Size Number SUMPS L Distance to nearest: Well Foundations �J! 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, 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 cert' ' following: "I®rrequi'r the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of rnia�11` " ' I The applicant d in ins:–Co p to awing on rev rse sidee7Signed +rlL3� °` ....��- Dater LYl R DEP TMENT USE ONLY Application Accepted by 01AAA Date �� Area Pit or Gro ut Inspection by Da a Final Inspection by Date Additional Comments: f O Stk 466-6781 L7 Lodi 369-3621 ❑ Manteca 823-7104 ❑.Tracy 635-6385 ,/Applicant - Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 11 INFO MOUNT DUE AMOUNT REMITTED GASH RECEIVED BY [ DATE PERM1T'NO. +.EH 13-24(REV.r/R 5) EH 14.25 l./ 4