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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) 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 or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Lot Size PM br TVA— City Owner's Name Address — Phone Contractor's Name License No. (2� -d'13 Phone 6^?6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION El 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 Casin ❑ Industrial ❑ Open Bottom .� ❑ Manteca Dia. of Well Excavation 9 C3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing l Specifications ❑ Public El Other L1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done E1Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Q Depth Filler Material (Below 501 TYPE OF SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septi+ system ithin m pefeeit'ed if public sewer is avaInstallation will serve: Residence v Commercial_ Other ` Number of living units: --/— Number of_bedr ms. Character of soil to a depth of 3 feet: —Water table depth's SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments, f� y PKG. TREATMENT PLT. Q-. Method of Disposal % i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation Property Line l E SEEPAGE PITS ❑ Depth Size Number r SUMPS Distance to nearest: We11 Foundation Property Line DISPOSAL PONDS ❑ E I hereby certify that 1,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 becorne 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." t '. V'K€ The applicantgust call fo all-re� r d ins ions.Complete drawing on reverse side.�- Signed Title: Date: O DEPARTMENT USE ONLY Are, Application l Application Accep by Date Pit or Grout Ins by _ V Date Final Inspection Date i Additional Comments: -- - - - - --- - -� ❑ Stk 466-6791 ❑ 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 CASH RECEIVED BY DATE PERMIT"N0. INFO 2f + EM 13-24 EH 13-24IREV.141531 4