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P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �1 1601 E. HAZELTI ON AVE., STOCKTON, CA G' Telephone (209) 466-6781, 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate Applicatian.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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local`Health District. '' D City " Lot Size PM Job Address -� r. PhoneOwner's Name ress Contractor ess icense No. Phone TYPE OF WELLIPUMNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11P: 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 - Dia. of Well Casing I ❑ Industrial ❑ Open Bottom ❑ Manteca ``` Dia.of 1Nell Excavation of Casing Specifications T ❑ D m stic/Private ❑ Gravel Pack 0 Tracy y� T of Grout L3 Public O Other j❑ Delta Depth of Grout Seal ype ❑ Irrigation 1. --Approx. Depth ❑ Eastern Surface Seal Installed by " Repair Work Done :a'# Type of.Pump r H.P. State Work Done Sealing Material (top 50') - Well Destruction c❑� Well Diameter 9 .. , Depth Filler Material (Belo '1 F TYPE OF SEPTIC CNORK: NEW INSTALLATION ❑ REPAIR/ADDITION WrDESTRUCTION Q ava1�abletiwi hne�fitted if public sewer is Installation will serve: Residence.}J 'Commercial Other + Number of living units:"-'-- Number of.bedrooms Water table depth r Character of soil to.a depth of 3 feet: I .11 Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg(? Method of Disposal [ PKG. TREATMENT PLT. ❑ Distance td nearest:_Well...Foundation .Property Line s Total length/size LEACHING LINE No. & Length of lines o '" oundation Property Lina FILTER BED ❑ Distance to nearest: Well g 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 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." ' The applican st c all uir i ctions. Compie r . g on e e side. r �2� r i 1 Title: Date: Signed I FOR DEPARTMENT USE ONLY Area rea Application Accepted by �� G� Pit or Grout Inspe + y , Date Final Inspection by Date rM- Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354338.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +EH 13-74(REV.t/8 51 7l� a/AS EH 1426