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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , ( ry PERMIT EXPIRES.1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 foo well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4. Jot%AddFess ` City Lot Size PM Owner's Name Address Phone W. Ile j Contractor's Name License No. Phone f O TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ~'� SYSTEM REPAIR ❑ ' OTHER ❑ # DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ti 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _---Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. ` State Work Done i Well Destruction El Wall Diameter Sealing Material (top 501 Depth iller Material (Belo ) �O TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Iff DESTRUCTION ❑ (No septic system permitted if public sewer is `\ available within 200 feet.) Installation will serve: Residence_,eCommercial Other Number of living units: Number of bedr' m Character of soil to a•depth of 3 feet: Water table depth SEPTIC TANK ❑ TypelMfg �J--r ' Capacity No. Compartments PKG. TREATMENT PLT;-Cl Method of Dis SPI Distance to nearest: Well Foundation� Property Line 1� I LEACHING LINE ElNo. & Length of lines - Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS ❑ Depth ize ,Number MP ❑ 'Distance to nearest: Well Foundation Property Line 11212y 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 Joaquih total Health District. Home owner or licensed agent's signature certifies the following: "I certify that 1n 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."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." The applicant must call �aIL quired ' s ctions. Complet d wing on ve side. -UKSigned Title: Date: �Q( l ... ! - FO DEPARTMENT USE ONLY t A. Ap ation Accepted by � Date � � � A a `� , or G out I spection by Date---F—e- Final Inspection by m Da P Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 x 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"N0. ., INFO � + EH13-24(REV. 1CM0 11D/831 �� 015 EH 4426