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i APPLICATION TOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA k /} Telephone (2()9) 466-6781 PAYMENT ✓`� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . RECEIVED (Complete in Triplicate) •- N [1 1��{� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workne nes rid'This application is made in compliance with San Joaquin County Ordinance No 549 for sewage oir No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distncy,*'t ENVIRONMENTAL HEALTH Job Address -- �� : PERMIT/SERVICES City Lot Size PM Owner's Name Address �f✓/ l/ f�Q�t1 I Contractor ;5 Address 055dS A&Ljucense No. EI) J Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FL13.1110—L PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f r �j n Dia. of Well Casing )Q Domestic/Private W Gravel Pack Tracy Type of Casing PVCe Specifications , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _„ ZM Type of ut ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by S Repair Work Done ❑ Type of Pump H.P. State Work Done a Well Destruction ❑ Well Diameter 'Sealing Material (top 50') dui Depth7 Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth I r' SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line SEEPAGE PITS ❑ Depth SizeNumber —, SUMPS ❑ Distance to nearest: Well Foundation Pro I perty Line DISPOSAL PONDS ❑ s: I_tereby 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."Contractors 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." ' s The applicant ust call for all req 'red inspections. Co let rawing on reverse si Signed GIC[ L r, ' Date: [ Ct FOR DEPARTMENT USE ONLY p Application Accepted by <� 4 Date a 0 Area Pit or Grout Inspection by Date F Final Inspection by Date ��! Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3921 ❑ 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 CK INFO CASH RECEIVED BY DATE PERMIT'NO. t p + EH1 -24IREV, /8 s! EH 144-29