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APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �,y✓ Telephone (209) 466-6781 J' PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) /or install the work This cation is madec n compliance writh SanoJoaqu the n Coungty O d nalnce Nto.549 for sewage or'No. 1862 for well/t to construt dpump and the Rules and hereinR gulations.of the San l Joaquin Local Health District. City Lot Size PM Job Address / Address 0- Phone Owner's Name f / Contractor Address icense No.,3 [� O Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERtWELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ......,,,,,,��sss...... Specifications �omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout — {" Public F1 Ot e 11 Delta Depth of Grout Seal I I Irrigation 7�prox. Depth l Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump— H P• State Work pone Sealing Material (top 50'1 Well Destruction ❑ Well Diameter 9 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) y Installation will serve: Residence— Commercial— Other f v Number of living units: Number of bedrooms v1 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 11\ Distance to nearest: Well Foundation 'Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line 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 Joaquin Local Health De%trict. 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, 1 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 ust cal or all required inspectio S. Complete drawing on reverse sid Signed X Title: Date: CDC FOR DEPARTMENT USE ONLY I Application Accepted by Date ' L� Area ` `� Pit or Grout Inspection by Date Final Inspection by Date. G Additional Comments: ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE A O CASH +.EH 13-241REV.1/N5) J J Q 47 �7 / �,«�C v ✓D EH 14-26 J