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APPLICATION FOR PERMIT '\ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon is /or install the work n describe . This cation is made inti compliance weiebyrith SanoJoaqu nthe SanCouJoanty Ordinanuin Local ce Nto.549 for sewage orh District for a 'No. 1862 for t to cwell/pump and the Rules and'R gulations of the San l Joaquin Local Health District. CLi /'-1-Y-d-P City 5-t0C KJOI-Lot Size 4�. PM Job Address X Owner's Name EL v I L( >3- 0 P I P i-\ A�dd ss EC-1,Z� 4)—c e_ 4(� Phone �5��71 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (,(► El Industrial D Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ElTracy Type of Casing Specifications (`1 Public F Other F1 Delta Depth of Grout Seal Type of Grout — I I Irrigation __.Approx. Depth ( I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION(No septic system in rmiitted if public sewer is availabeet Installation will serve: Residence_ Commercial_ Other 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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, 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."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 call re uir inspections. Complete drawing on reverse side. Signed X Title: L7.' HO Y Date: FOR DEPARTMENT USE ONLY Application Accepted by Date '' Area (/�3 Pit or Grout Inspection by Date Final Inspection by Date 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ; ITE PERMN CASH O. INFO EH 13-24(REV.1/N 5) !/ EH 14-26