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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091466-6781 PERMIT EXPIRES 1 YEAR 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 9 for a or No. 1862 for we11/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.54 sewa g Local Health District. Q/(1C City Lot Size C PM Job Address -7 s 4t%it)^ � �` Phone v�s- /3 � ' Owner's Name Addres _ - �. _AltAddress D. License NO.3Q _ _Phone Contractor f' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 I'1 Public I] Other ll Delta Depth of Grout Seal Type of Grout---. I l Irrigation } —Approx. Depth 1 I Eastern Surface Seal Installed by State Work Done Repair Work Done 171 Type of Pump H,P. \ Well Destruction ❑ Well Diameter Sealing Material {top 501 N� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION FI REPAIR IAUDITION DESTRUCTION I i INo septic lable system thin m rented if public sewer is w Installation will serve: Residence`Commercial 3 Other Number of living units: NumbePF��Method Character of soil to a depth of 3 feet: Water table depth No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ of Disposal 'Distance to nearest: Well Foundation�? Property Line t k Total length/size-5 �., LEACHING LINE 0No. & Length of lines ��,, f I 0f Foundation �i 0l Property Line j FILTER BED ❑ Distance to nearest: Well _ �r SEEPAGE PITS 1<Depth ��t_Size f Number l 4 Property Line w� SUMPS r ❑ Distance to nearest: Well� ,Foundation DISPOSAL PONDS_ ❑ — hereby certify that k have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r r I Y Y rules and regulations of the San Joaquin Local Health Di§trict:{ F Home owner or licensed agent's signature certifies the followirig: 111 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this s permit is issued, i shall employ persons subject to workman's compensa tion laws of California." ' The applicant ust call r a required inspections. Complete drawing o everse side. Signed f t Title: �� Date: X FOR DEPARTMENT USE ONLY I : �1 Date Z Area y A plication'Accepted by � by / /. Final Dat Pi or Grout Inspection by/ f y Date Inspection� m I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2409, Stk., CA 95241 i4 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24(REV.I/As) EH 14-26