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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r o 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon is hereby made tt and/or in all the work n described.This cation is made inticompliance with SanoJoaqu nthe San County OrdinaJoaquin lnce Nto.District549 for sewage or permit 1862 for cwell/pump and the Rules and IR Regulations of he San l Joaquin Local Health District. 4� /�r!!0 City Lot Size PM Job Address Owner's Name 1�I ' L Address [� ��u' '� _ Phone 3 Contractor's Name `� NI,� /7��License No. �7F � � 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \� L1 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation ---Approx. Depthh�//��❑�Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.H•P• State Work Done , Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabptiwi system emitted if public sewer isavle Installation will serve: Residence— Commercial_ Other (INN 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. ElMethod 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 ❑ Depth Size Number SUMPS ❑ 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 ensation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's comp 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 c II for al req d inspe tions. om lete drawing on reveme side.- Signed ideSigned Title: Date: FOR DEPARTMENT USE ONLY b -� Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by �� ) J✓�f`"`{ Date c r" Additional Comments: e R� ❑Stk 466-6781 ❑ Lodi 369,361 O Manteca 823-7104 ❑ Tracy 835485 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box!:Dqtkjt� ., CA 95201 FEED CK CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.10/83) EH 14-26 ell