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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 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 Sari`Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address ^ � City 'Lot Size �. Owner's Name Address Phon¢ Contractor G y ense No. - Phone 4 TYPE OF WELL/PUMP. !I` NEW WELL C1 WELL REPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �. dh (`1 Public (_l Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation LN ..Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material (top 50') Dei pth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION [ ] DESTRUCTION [ ] (No septic system permitted if public sewer is lJ ) available within 200 feet.1 Q installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms o- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ (2 No. Compartments r Pzl PKG. TREATMENT PLT. ❑i Method of Di osai t Distance to nearest: Well F undation .Property line _ 4 1' LEACHING LINE ❑ No. & Length of lines '� `Total length/size FILTER BED ❑ Distance to nearest: Well f A. 7 Foundation s. Property Line / SEEPAGE PITS, - r I I Dept Size ''Number ` SUMPS Ll Distance to nearest: Well? 4 Foundation — Property Line i DISPOSAL PONDS 1_1 ` I ; Thereby certify that I have p'r�epared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and F rules and regulations of the San Joaquin Local Health District. . 4 'r 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." Contractors 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 parsons subject to workman's compensa- tion laws of California." 11 ` The applicant t ca all re wired in cti ns. ComplZdrang on reverse side. ASigned X e: Data: FOR DEPARTMENT USE ONLY Z_ Appiicatio ccepted by Date 41—�`— � Ar � IL K OX!: Date nal inspection by Da e Additional Comments: �I ❑ Stk 466-6781 ❑ Llodi 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 95201FEE INFO �AryMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYDATE P¢ERhAZIT'NO. j +.EH13-24(REV.iIn5) ` } 1 ,` nJ} EH 14-28 :.J