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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n qZ ��.Sty`/t-GQ i rco , Job Address r City Lot Sizeo�aal! fJt�PM P Owner's Nam _-e�l �.r rf ! �_ t Phone of Contractor's Name j0�0� License No Phone TYPE OF WELL/PUMP: NEW WELL 2- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Z;--- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /' ?/) SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _A22-t-_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavati Z47 Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type o out ❑ Irrigation --Approx. Depth ❑ E stem Surface Seal Installed by opt Repair Work Done ❑ Type of Pump , t H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ..� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 �I 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 ❑ 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 h rules and regulations of the San Joaquin Local Health District. 4 \ 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 a 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 t ca r all required inspection omplete drawing on reverse side. r Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by x { f� Date Area r Pito Grout spection by Date ✓`��Final Inspection by �� ate 13 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE CPERMIT�`NO. + EH 13-24{REV.10!831S O LAA f131 EH 1126 Y y� O LAA Lei L