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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. TMs 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. Job Address d <[ f t., .-, r City ` of Size Owner's Name Address Contractor's 5- 1►7-3 0- PM Phone Phone 5>1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 47— SEWER LINES DISPOSAL FLD. 5 PROP. LINE FOUNDATION AGRICULTURE WELL OTHFR WFI I oP7e ictmAne INTENDED USE ❑ Industrial omestic/Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ SEPTIC TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pen Bottom ❑ Manteca Dia. of Well Excavation D Gravel Pack ❑ Tracy Type of Casing ❑ Other ❑ Delta Depth of Grout Seal -1 --Approx. Dzax:H.P. S ace Seal Installed by�i Type of Pump State Work Done _ Well Diameter Depth Sealing Material (top 50') Filler Material (Below 50') K: NEW INSTALLATION ❑ REPAIR/ADDITION Q Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other Dia. of Well Casing Specifications 12 Type of Grout f (No septic system permitted if public sewer is available within 200 feet.) Water table depth _ Capacity No. Compartments Method of Disposal Property Line Total length/size Property Line Number Property Line 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." 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 must all fo all required inspections. Complet r Ing on reverse side. Signed Title: Date: \fl 101 FOR DEPARTMENT USE ONLY Application Accepted by' r CDate Area � f Pit or Grout Inspection by Date Final Inspection by�� patef j a Additional Comments: Allf / ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO + EH 13-24 (REV. 10l83f� J q EH 14-26 I p RECEIVED BY DATE PERMIT"N0. t Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Method of Disposal Property Line Total length/size Property Line Number Property Line 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." 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 must all fo all required inspections. Complet r Ing on reverse side. Signed Title: Date: \fl 101 FOR DEPARTMENT USE ONLY Application Accepted by' r CDate Area � f Pit or Grout Inspection by Date Final Inspection by�� patef j a Additional Comments: Allf / ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO + EH 13-24 (REV. 10l83f� J q EH 14-26 I p RECEIVED BY DATE PERMIT"N0. t