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I 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) t and/or install the work cation is radecnt'ompliance with Sano oJoaquln County Ordinance the San Joaquin lNo.549 for sewage orHealth District for a 'No. 1862 for t to cwell/pump and the Rules and herein Regulations of the aSan rJoaquin Local Health District. A L �, A/ City �G Lot Size� PM Job Address Owner's Name 4& ff Address b a� �� itZA Phone �] T,^ /fid License No. 75. _Phone y� Contractor;Q Z' Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTflUCT1, 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ F- OTHER ❑ r 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 C Open Bottom O Manteca Dia. of Well Excavation 'Dia. of Well Casing .41 ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing __ Specifieations ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .-Type of Grout-- 0 ut -❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by_ Repair Work Done ❑ Type of Pump H.P. State Work Done--.- Well Destruction ❑ Well Diameter Sealing Material (top 50T Depth__ Filler Material (Below,501 TYPE OF SEPTIC WORK: NEW INSTALLATION TREPAIR/ADDITION ❑ DESTRUCTION ❑ (Neilable septic iystem emitted if public sewer is Installation will serve: Residence.__ Commercial e!:�_Othet – Number of living units: Number of bAir_ drooms Character of soil to a depth of 3 feet: Water-table depth_ SEPTIC TANK C1 Type/MfgCapacity No. Compartments _ Method of Disposal PKG. TREATMENT PLT.❑ f� Distance to nearest: Well/pa Foundation �� Property Line LEACHING LINE cNo'& Length of lines �— Total length size_ :P-- FILTER BED . ❑ Distance to nearest: Well Foundation /ifs Props _Line SEEPAGE PITS ❑ Depth Size Number SUMPS J 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: "I certify that in the performance of the work for which this permit is issued, I shall not empty 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. .� �_ Title: — Date: Signed X_. __ FOR s PART'MENT USE ONLY Application Accepted by Date Area �—� Pit or Grout Inspection by Date _ Final- Datelnspection by - Additional Comments: 7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_, P.O. Boz 2009, Silt., CA 95201 CK# FEE AMOUNT DUE AMOUNT REMITTED CASH EC H REIVED BY DATE PERMIT NO. INfO - - + EH r3-24(fl EV.,;R5: EH 1428 ' ��