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APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. "HAZE67ON;AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED.- (Complete SSUED.(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 Ordinance No.649 for se age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. jt, �- R� r p t• /Lot Size, err. .' y- PM_ Job Address Cit - _ Owner's Name _ Phone- el Contractor's Name o. Phone D TYPE OF WELL/PUMP: 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 x Type of Casing ° r�Spec`ificafion's'� - � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -.--Approx. Depth ❑ Eastern Surface Seal Installed by 1 z Repair Work Done ❑ Type of Pump W.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONV DESTRUCTION ❑ (No septic system permitted if public sewer is. I ' available within 200 feet.) Installation will serve: Residence_zCommercial_, Other t (b Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ e Method of Disposal Distance to nearest: Well FoundationProperty Line- . ` Total len th/size A LEACHING LINE E3 No. & Length of lines ; 9 FILTER BED .❑ -Distance to nearest: Well= Foundation Property Lin,`N SEEPAGE PITS ❑ Depth Size i Number•" �%/ -SUMPS Distance toropeynearest: Well I Foundation Prty Line'' ' DISPOSAL PONDS ❑ r �° f I hereby certify that I have prepared this application and that the work will be done in accoTdance..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 workfo rich this permit is issued, I shall not employ person in such manner as to become subject to workman's_compensation laws of'California."Contractors hiring or subri 6 actingsignature p Y anY certifies the following: "I certify that in the performance of the work for which this permit is.issued,Ishall employ persons subject to workman's compensa- tion laws of California." '^ ., The applicant mus calwiR all re wired&�w S. Complon re se. Signed t 7 Date: 1 k FOR DEPARTMENT USE ONLY Application Accepted by Date�� —v Ar — p�/�_ Pit or Grout Inspection by w Date Final Inspection by_ Date p . Additional Comments: ❑ Stk 466-6781 .. - ❑ Lodi 369-3621 Ll Manteca 823-7104 El-Tracy 83x6385 " I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,�Stk.;CA 95201 FEEAMOUNT DUE ` AMOUNT REMITTED CASK RECEIVED BY DATE -'PERMIT"'NO, {NFO _ + EH 1324(REV.IWO �' F � r / I C:; B 4—1 21 EH W28 -- - - - .. -