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APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i I (Complete in Triplicate) quin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joa e or No. 1862 for well/pump and the Rules and Regulations o1 the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag Local Health District.r 1 A G� of Size PM Jab Address Er City I Owner's NamekA: b Address ^3 Phone Contractor > Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE DISTANCE TO NEAREST: EPTIC SEWER LINES " DISPOSAL PROP. LINE FOUNDATION AGRICULTURE�WELL WELL PITS/SUMPS INTENDED USE STYPE OF WELL PR_OBLf EM A+ N SPECIFICATIONS ❑ Industrial t ❑ Open Bottom ❑ Manteca of Well Exca n Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy~ ^--Type of-Casing k Specifications t i'1 Public ❑ Other elta Depth-of"Grout Sh I Type of Grout — A rax pth I 1 Eastern Surface Seal Installed by I I irrigation —�� pq Repair Work Done ❑ Type ump °__H:P: _ # State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 1 Depth j + ( Filler Material (Below 501 TYPE OF SEPTIC,WORK:--NEWINST-ALiL-ATION-t l� REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is available.within 200 feet.) installation will serve: ResidenceCommercial_.� Number of bedrooms Other Number of living units: ` f Character of sail to a depth of 3 feet: r .T-Water table depth " - � No. Compartments Capacity 1 SEPTIC TANK ❑ Type/Mfg ` , Method of Disposal PKG. TREATMENT PLT. ❑ -t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines yTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation = Property Line SEEPAGE PITS I i Depth Size Number SUMPS Cl Distance to nearest: Well Foundation I Property Line 3 z DISPOSAL PONDS ❑ I her 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 pework for which this permit is issued, 1 shall not rformance of the 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 fallowing: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of Califomi f t The applicant mu I f all re ins to drawing on reverse side. I Signed X Date: FOR DEPARTMOVT USE ONLY Date % �3 ..� "t Area , Application Accepted by NgS721 ` _ G Pit or Grout Inspection by Date Final Inspection by Additional CommentsA;%F5;;11 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. O INF t + EH 43-24 TREY,r i w sl EH 14.26