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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 IZA� (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 s wage or.No. 1862 for well/pump and the Rulnd Re �at ons of the San Joaquin Local Health District. �'! � t ��_ C ��r Q� �� ,� Job Address �T City Lot Size L0�e PM Owner's Name ��lf Address { Phone�XS Co trn actor's Name��'� �r1se No." 7'` '- r ^- Phone" TYPE OF WELL/PUMP: NEW WELL —+ 1 WELL REPLACEMENT•❑ DESTRUCTION ❑ PUMP INSTALLATION ice' SYSTEM REPAIR ❑ OTHER ❑ �. DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLp, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial ottom ❑ Manteca S g Dia. of Well Excavation Dia. of Well Casing r otic /Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications • ❑ Public E3 Other 171 Delta Depth of Grout Seal Type Gro t ❑ Irrigation —Approx. Dept ❑ astern Surface Seal Installed by ' Repair Work Done F1Type of Pump .N.P._57 State Work Done Well Destruction ❑ Well Diameter'"- Sealing Material [top 501 ,. Depth Filler Material IBelow 50').`k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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.E Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDS' ❑ Distance to nearest: Well Foundation Property.Line ` y SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line + DISPOSAL PONDS lE] .is 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 r»anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certifyahat 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." f. The applicant-mus all for all required inspections. C plate drawing on reverse side. Signed f Title: Date: R FOR DEPARTMENT USE ONLY Application Accepted by Date { Area ` Pit or Grout Inspection by Date Final Inspection by Date l A� Additional Comments:' ❑ Stk 466-6781 ❑ 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 95201 FEE INFO AMOUNT.D^UE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT"N0. + EH 13-24{REV.10/831 �C I p� / 7 EH 1426 LLL��J