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VAPPLICATION 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 heieby 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City ` Lot Size PM Job Address t # Address Phone p Owner's Name q Contractor C r a Address License No:�[ Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of Well Casing g ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — Type of Grout ❑ Public 4i7 Other ❑ Delta. Depth of Grout Seal - I 1 irrigation �.Approx. Depth I I Eastern a t. t Surface Seal Installed by i g H.p P. State ork Done_ Repair Work Done ❑ Type of Pump 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 r ii Depth Filler Material.{Below.50') ; TYPE OF SEPTIC WORK: NEW INSTALLATION f.I /ADDITION t I DESTRUCTION 3vailabpelwithin 200 feetitled if public sewer is Installation will serve: Residence_ Commercial Other L 4' I 't j Number of living units: Number of bedrooms r t_ Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK El. Type/Mfg "_ Capacity No. Compartments PKG. TREATMENT PLT. EJ of Disposal Distance to nearest: Well Foundation Property Line 3 i LEACHING LINE ❑ No. & Length of lines m Total length/size FILTER BED ._--`—❑ Distance to nearest: Well FoundationPropert'�y e SEEPAGE PITS I I Depth Sizer/ j Number ,` SUMPS Cl Distance to nearest: Well Fofundartion. } Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulatigo"heSan Joaquin Local Health'District. Home owner t's signature certifies the following: "! certify that in the performance of the work for which this permit is issued, I shall not employ any ranner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the oil fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- The laws o CThe applic tl required inspections. Complete drawing on reverse sj'de. _, Title: Signed X Date: i FOR DEPARTMENT USE ONLY ri Application Accepted byDate Area V Pit or Grout Inspection by Date Final Inspection b Date i Additional Comments: ❑ Stk 466-6781 ❑ 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, 5tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK V RECEIVED BY DATE PERMIT*IVO. INFO CASH (® +.EH13-24(REV,tin51 EH 14-26 t`