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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 771 Job Address e o s City Lot Size PM Owner's Name ddress Phone _. Contractor Address MO 6 80A�_; License N Phon —33 TYPE OF WELL/PUMP: NEW WELL-%_ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATIO 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 iI I-] Industrial M"v ' -E] Open Bottom ❑ Manteca Dia. of Well Excava i Dia. of Well Casing ❑ Domestic/Private ""❑ Gravel-Pack: ❑ Tracy Type of Casing Specifications ❑-Public--- -- 0 Othef ❑ Delta Depth of Grout Seal Type of Grout ``:Xtrrigaticin' _A'pprox. Eastern Surface Seal Installed by Repair-Work Done,❑ Type of Pump H.P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j P Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public ^ " 4 available within 200 feet.) \ Installation wi Residence_ Commercial Other Number of living units: Number of bedrooms r j Character of soil to a depth of 3 e ter table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ - l. ,, Method of Disposal Distance t7nea!rest:,, Well .- ation Property Line ---------------------------------------------------- LEACHING LINE ❑ No. & Length of line otal length/size FILTER BED ❑ Distance t rest: Well Foundation arty Line ' r � SEEPAGE PITS Depth. Size Number SUMPS `❑ Distance to nearest: Well Foundation } Property Line OSAL PONDS F1- 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 arty 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." 1 The applic �callwiredinspections. Complete drawing on reverse side-� ' 9 Date: --- 3 -- ' Signed Title: ` c�.�—=�-'"`�_Q/� � FOR DEPARTMENT USE ONLY Application Accepted by Date Area x Pit or Grout Inspection by E Date Final Inspection by� /� Oltel_Q'J3- Additional Comments: ❑ Stk 466-6781 EJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354MM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. CASH +EH 13-24(REV.s/e sl EH 14-28 �