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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) District for a Ito construct is cation A plication is ereb worth a to the S nnCoumy O durance lth 549 for sewage or No 1862 forwell/dpuoherein mp and the Runes and R gulations of the San'Joaquin de ance San 7 m Local Health District. 0 ^ ' � City Lat Size PM Job,Address Address Phone Name ame I, - w ense No. Phone Contractor ess TYPE OF WELL/PUM NEW WELL El WELL REPLACEMENT ❑ OESTR TION El SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ PROP. LINE S DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEPITS/SUMPS FOUNDATION AGRICULTUREWELL OTHER WELL - S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing El industrial E3 Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout FI Public 1711 Other F1 Delta Depth of Grout Seal yp I 1 Irrigation �..Approx. Depth I i Eastern Surface Seal Installed by! '— "State Work Done Repair Work Done El Type of Pump �H pT �— f Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth Filler Material (Belo 50') TYPE OF SFPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION i I (No savailabeti:be system feet.) if public sewer is l r 5 ` installation will serve: Residence' Commercial_ Other . +� 1 Number of living units: Number of bedrooms ! �, j e 111 t Wa Character of sail to a depth of 3 feet: No. s SEPTIC TANK ❑ Type/Mfg Capacity MealPKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well -Foundation Property.Line t Number SEEPAGE PITS l 1 Depth I SUMPS LlDistance to nearest: Well Foundation Property Line SAL PONDS ❑ I hereby certify that I have preparedlthis 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 Di%trict. 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 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 applicant must call for all equired ' etions. Com to wing on reverseside. ` — Date: Signed Title: s OR PEPARTVtENT USE ONLY �`—�-- f Date Area / Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 El 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 CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH G 3 +.EH 13-24(REV.5/x 5) _ EH 14-2e _