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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 p PERMIT EXPIRES TYEAR FROM DATE ISSUED (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. 4DPQ cr city k Lot Size PM Job Address c ' Owner's Name J-50.JDD i �wtn � Address � � � �t41a`T Phone A-16'<1 71 r� Contractor le/F Address License No. Phone_ TYPEOFWELL/PUMP: NEW WELL 171WELL REPLACEMENT ❑ DESTRU PUMP INSTALLATION 0 SYSTEM REPAIR ElOTH 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 i 0 Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal x Type of Grout I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ .. Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Se'a'lir_ig Material (top 501 j Depth -Fillet Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION {.l REPAIR/ADDITION LI DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) 'Installation will serve: Residence— Commercial— Other Q 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 PKG. TREATMENT PLT. 171. Method of Disposal 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 l 1. Depth Size Number SUMPS ❑' 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 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." Kn, Theapplica ust cal for a!I reections. Complete drawing on reverse side. XSigned Titla: (1 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ' � Area Pit or Grout Inspection by I Date Final Inspection by Date 1 � Additional Comments: Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantaca 823-7104 ❑ Tracy 835-6385 - Applicant- Return all copies to:.Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C1C RECEIVED BY DATE PERMIT NO. t INFO CASH + EH13-24MEV.r/AS) EH 14.26