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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA N ID Telephone (209) 466-6781 No y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n RCSB (Complete in Triplicate) CiD4 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 OT No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.; Job Address 0 City Lot Size PM Owner's Name+' Address Phone ,ry Contractor G ' Address License No. Phone TYPE OF WELL/PUMP: 7 NEW WELL ❑ WELL REPLACEMENT E DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIK.C TAN ' SEWER LINES DISPOSAL FLD. PROP. LINE F60NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '�-.: INTENDED USE , TYP .OF:WtLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ' El Open Bottom L1 Manteca ' Dia. of Well Excavation Dia. of Well Casing [ ` El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {—+-- ❑ Public 13 Other L) Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern t Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P; State Work Done— {� Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is 1� Ii vailable within 200 feet.) �[1 r Installation will serve: Residence— Commercial, Other Number of living units: Number of bedrooms f ^ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ► Capacity No. Compartments 1 Method of Disposal PKG. TREATMENT PLT. 71a :'b Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line . SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that 1 have prepared this application and that the work w rules and regulations of the San Joaquin Local Health District. that in the performance of the work for which this permit is issued, I shall not Horne owner or licensed agent's signature certifies the following: "I certify 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 applica must call for all required inspections. Complete drawing on reverse side. Signed Title: 46� Date: -0-9 7 F DEPARTMENT USESL �(D�(J Application Accepted by Date Area AAZ Pit or Grout Inspection by Date Final I pection by Date Additional Comments: , ❑ Stk 466-6781 El 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE7 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. (NFD ,uta]/R'� EH 13-24(REV.I/H5 -�uv 0 'l `t.J �•`-' V 7- EH 14-20