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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 N O W PERMIT EXPIRES 1'YEAR FROM DATE ISSUED N13 `�Pl , I (Complete in Triplicate) S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri ed. This application is ` made in compliance with San Joaquin'County Ordinance N 549 for sewag 4r No. 1862 for well/pu and the Rules and Regulations of the San Joaquin f Local Health District. 4 Job Address Q City Lot ize PM Phone V-L7- a zS Owner's Name&— Contractor ress L cense;_'N + Phone v 4 TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLAC ENT 11DESTRUCTION El t PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER,❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FCO.— PRLINE i FOUNDATION AGRICUL 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 y�:' Specifications 1-1 Public ❑ Other ❑ Delta Depth of'Gir Seal - Type of Grout _ ` 1 t Irrigation —,,Approx._Depth_I I Fa rn .r -Sur.face.SealJnstalled by ` { Repair Work Done ❑ Type of Pump H.P. = State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 – TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION P1 (No septic system permitted if public sewer is t ^ available withi 200 fee r Installation will serve: Residence_ Co- mercialY— ther Number of living units: Number of b room Character of soil to a depth of 3 feet: } Water table er SEPTIC TANK ❑. Type/Mfg Capacity g No. Compart a is r PKG. TREATMENT PLT. 1-1 ; Method of Disposal i. Distance to nearest: Well Foundation Property Line w LEACHING LINE ❑ No. & Length ofIi s Total length/size FILTER BED ❑, Distance to neare v We Foundation Property Line 4,1 r � SEEPAGE PITS I I Depth Size - Number I SUMPS ❑ Distance to n arest: Well Foundation Property Line DISPOSAL PONDS ❑r } 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 t 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 C lifornia." The applicant ust call for squired in ctions. Complete drawing on reverse side. I Signed X itle: Date: FOR PARTMENT USE ONLY A f Application Accepted by 4 _ Date �� Area r Pit or Grout Inspection by Date Final Inspection bV Date I Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy 835-6385 Y Applicant - Return all 1 opiei to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H KSRECEIVED BY DATE PERMIT'NO. INFO CCA r� EH 13-24 13-24(REV.t/x5) EH 14-2B