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APPLICATION FOR PERMIT ! i 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) 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 an Joa in�Cf un �0 din nce No�` 9 for �yvag6�or,N�� 1$�for wel�,(�p and the Rules and Regulations of a Sin Jofa uin ^ Local Health District. 7 /Yo/'�!j J% "�4 r. ad �f f Job Addres ` / �` City 7 of Size PM X, Owner's Name Address 7 Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONI,/ 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 f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout /�/i• ` I I Irrigation __.-Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Done.— Well Destruction LJ Well Diameter Sealing Material (top 50'1 !2!5� �/f�t!/st' Depth c Filler Material (Below 50 _ - Sir TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I (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 i 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 LEACHING LINE ❑ No. & Length of lines Total length/size �r FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS i I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "locartify 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."Contractors 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 mu call for ail required inspections. Complete drawing on reverse side. Signed N TiNe: � '�� Date: l� FOR DEPARTMENT USE ONLY // Application Accepted by Date(/ Area r / Pit or Grout Inspection by Date Final Inspection by Dater Additional Comments: f7l Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 623-7104 ❑ Tracy 5-6385 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 H RECEIVED BY DATE PERMIT*NO. INFO t +,EH13-24(REV.I/N5) �C cr, I� "`\+y-�G EH 14-26 '^� r