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a APPLICATION. FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1IYEAR-FROM DATE ISSUED'` (Complete in Triplicate) cation is Health ApplicationisNance with Sanothe San Joaquin Joaqu'rn County Ordinance No.District549 for sewage or rt to construct No. 1862 for well/PUMP install nd the Rules and Regulations of the San r Joaquin made in compliance Local Health District. Cr Lot Size PM Job Address -::Phone = E Owner's NI Address -1License No.o �; Phone Contractor , � TYPE OF WELL/PUMP: EW WELL LJ REPLACEMENT 1-JDESTRUCTION 11 SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION IDI SEWER LINES DISPOSAL FLD. PROP. LINE ! DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private EI Gravel Pack [I Tracy yp g Type of Grout ❑ Public El other ❑ Delta Depth of Grout Seal V i 71 Irrigation --Approx. Depth CJ Eastern Surface Seal Installed S Repair Work Done ❑. Type of mp. H P State Work Done Pu well Destruction ❑, Well Diameter T�. Filler ng Material (top 50') Depth >� Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION='❑ RR/ADDITION ❑ DESTRUCTION aNailableeptrwithin e200 permitted if public sewer is Installation will serve:, Residence— C ,.- "o, cial - Other ,� x � m Q � Number of living units: Number of bedrooms Wate'f table'depth i I Character of soil to a depth of 3 feet: No. Compartments �] SEPTIC TANK ❑ Type/Mfg Capacity (/ f SJ Method of D sposal n PKG. TREATMENT PLT. ❑ f Y operty Line r Distance_to-nearest:.,..-wWell„ Foundation Total length/size LEACHING LINE ❑ No. & Length of pines property Line„ . ❑ Distance to neareIs�t: ' Well Foundation FILTER BED — SEEPAGE PITS ❑ Depth !` Size Number i � Property Line _ SUMPS [D Distance to nearest: elf Foundation DISPOSAL PONDS ❑ 1 hereby certify that 1have prepared this application and thai 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. I 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 f 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 r quire ins ions. Complete drawing on reverse sid c Date: s] '— Title: �� F Signed X • FOR DEPARTMENT USE ONLY �- fDate Area Application Accepted by' S 1 Date Final Inspection by Date Pit or Grout Inspection by Additional Comments: Stk 466-6781 El Lodi 369-3621 ❑ Man823-7104 ❑ Tracy 835 6385 teca Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-`NO- FEE ERMIT`NO. INFO + EH 13-24(REV..S/e5} EH 14-26