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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �} f 1601 E. HAZEL T ON AVE., STOCKTON, CA # Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 49 for No. 1862 for well/pump and the Rules and Regulati Ordinance No. 5or sewage ons of the San Joaquin Local Health District. Job Address 0 - — City at Size PM Ia— �1 r, Owner's Name �� ' " ' ua r address 3 'O r Phone 7 1510'r Contractor _Address License No. Phone TYPE OF WELL/PUM NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications' l'1 Public ❑ Other �,� ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Apprbx. Depth l I Eastern Surface Seal Installed by - Repair Work Done [3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Wt Depth Filler,Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION [.I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG. TREATMENT PLT. ❑ � � UIFffff— Method of Disposal Distance to ne rest: EXnrty Line LEACHING LINE ❑ No. & Length of IiParmit muaye expired.withut, length/size FILTER HED ❑ Distance to neanwork ,J 1 �� i�iPr��y Property Line SEEPAGE PITS i I Depth 'Dl [—°Si�r � �' `�aalth iVi5lfdber SUMPS Ll 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 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, l 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 o California." The appl' a must call for 1 squired ins ctio . Co pie drawing on reverse side. Signed Title: Date: I FOR DEPARTMENT USE ONLY IBJ �nj Application Accepted by Date �[ r �`� Area Pit or Grout Inspection by --I ate Final Inspection by Date Additional Comments: 'L� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M nteca 823-7104 ❑ Tracy B35-6385 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'NO. + INFO J9 '+ +.EH13-241REV.t/n51 �� EH 14-26