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0 APPLICATION FOR PERMIT I Il: SAN JOAQUIN LOCAL_HEALTH DISTRICT 1601 E. HAZEI_T.ON,.AVE',-STOCKTON, CA .. Telephone',(209) 466-6781 �l PERMIT EXPIRES.'I YEAR FROM DATE ISSUED - I. I (Complete in Triplicate) 3 w 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 Ordina a No.549 for sewage or No.-1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address t Size r _ l r� Owner's Name ress __ Phone , l� Contractor's Name `�'��r/ '!� Se No. 5 Phone 0 \ TYPE OF WELL/PUMP: i. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �] PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 15-0 SEWER LINES DISPOSAL FLD aaOP. LINE �149 0 FOUNDATION AGRICULTURE WELL/_,5OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3 Industrial Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ! EA- m>�/Private ❑ Gravel Pack ❑ Tracy Type of Casing , Specifications ❑'Public F1Othe!r ❑ Delta Depth of Grout Seal lj~CJti �-�- Type o Gr ut ❑}Irrigation ------Approx. Depth ❑ Eastern Surface Seal Installed by Wek Repair Work Done ❑ Type of Pumper H.P, State Work Done ! Well Destruction ❑ Well Diameter Sealing Material`(top 50') k Depth �I Filler Material [Below 501 "TYPE OF SEPTIC WORK: NEW:INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted'if.public,sewler�is - installation will serve: Residence_ Commercial_ Other Number of living units: II 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. ❑ I. Method of Disposal Distance to nearest: Well Foundation- Property Line II. � LEACHING LINE ❑ NoI& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line "f II SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I� I hereby certify that I have prepari[d 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 JoaquimLocal 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 mannef,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." I�i The applicant mu call f II req'1 iced inspections. Comple wing on reverse side. Signed _ Title: _ - Date: != FOR DEPARTMENT USE ONLY Application Accepted by Date Area G�Pit or Grout Inspection by — final Inspection Additional i Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 'INFO K 4 AMOUNT DUE A�QMO�U^NT�REMITTED SASH RECEIVED BY DATE PERMIT-No. + EH 1124(REV.10183) EH W28 - xi. _