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APPLIQI TION TOR PERMIT ti SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZELTON 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 well/pump and .thi#ules and.Regulations of the San Joaquin Local Health District. Job Address City PM - a�_ �— , T Owner's Name r p 1A r� L� Address n ,M• Phone Contractor's Name License No. �/ e2 Ph.09' TYPE OF WELL/PUMP: NEW WELL F-1WELLREPLACEMENT ❑ DES'rRUCTIQN ❑ `.r r= PUMP INSTALLATION ❑ SYSTEM REPAIR CfTWER © {' DISTANCE TO NEAREST: SEPTIC,TANK _/�f1 r SEWER LINES DISPOSALf FLS PROR. LINE, 1 W ;. FOUNDATION AGRICULTURE WELL OTHER WELL: PITS./,SUMPS_ . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_ S ❑ Industrial ❑ Open Bottom` „❑ Manteca Dia. of Well Excavation :Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ;'Specrfi '666s ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of.`Grout ❑ Irrigation ---Approx. Depth Eastern Surface Seal Installed by r Repair Work Done I Type of-Pump H.P. State.Work bone " I Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if.public sewer is available within 200,feet.).: Installation will serve: Residence_ Commercial_ Other ', s Number of living units: Number of bedrooms Character,of soil to a depth of 3 feet: *Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No..Compartments, PKG. TREATMENT PLT. ❑ Method of Disposal ` " Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size s- FILTER BED ❑ Distance to nearest: Well Foundation -Property Line. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation ==Ploperty,Line DISPOSAL PONDS ❑ 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."Contractees 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 California." The appjiparsfum st for all require ctio . Complete drawing on side. i Signed X Title: / ��ST, , ,., . _ Date' F DEPARTMENT USE ONLY fl Applica on Accepted by Date apirea � ^ Pit or Grout Inspection by u Date Final Inspection Additional Comments: �- . ❑ Stk 466-6761 El Lodi 389-3621 El Manteca 823-7104 El Tracy 835-83854.• , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk.;CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE .'PERMIT'NO. INFO CASH EM 13-24 EH 1128(REV.10183)