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�_. 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 f .3 . (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.549 for sewage or No. 1862 for well/pump a Local Health Districtnd the Rules and Regulations of the San Joaquin : '� Job Address S F City C!i Lot Size PM Owner's NameAddressQV Phone Contractor_S� i� Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E) DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll �' - OTHER'[D " 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 —*,Ml- EJ Gravel Pack ` ❑ Tracy Type of Casing = Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 411! L ❑ Irrigation -._ Approx. Depth EJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter I Sealing Material (top 50') Depth 1 Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ REPAIR/ADDITION ❑ DESTRUCTION No'septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: R omrnercial_ Other ~" V Number of living units: __V__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well I Foundation Property Line LEACHING LINE '❑ No. & Length of lines Total length/size FILTER :BED ❑ Distance to nearest: Well Foundation Property Line I 3 SEEPAGE PiTS ❑ Depth +1 Size Number SUMPS 1714 .Distance to nearest: Well Foundation-- Property Line DISPOSAL PONDS ❑ j -- 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 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 for all required inspections. Complete drawing on reverse side. +41-C Signed � 7 Title: Date:' FOR DEPARTMENT USE ONLY .► Application Accepted by 11— Date ri l �J Area Pit or Grout Inspectio Date Final Inspection by y Date r Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk„ CA 95201 FEE AMOUNT DUE A INFO C SH MOUNT REMITTED RECEIVED BY DATE PERMIT'NO. r EH r3-24 MEV.1/8 51f �( •' -