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APPLICATION FOR PERMIT �= ` SAN .lOAQUIN LOCAL HEALTH DISTRICT �E 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M t (Complete in Triplicate) e to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby mad made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weand the Rules and Regulations of the San Joaquin li1pump Local Health Distric+ �� r ! Lot Size PM Job Addre l sd I �� Address frrPhone Q I �-0wner's Name � - � , � 1 Address License Na. Phone Contractor �.--- } 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑- SYSTEM REPAIR El PROP. ❑ 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 Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation ❑ Industrial 6 Type of Casio Specifications — -4 El Domestic/Private ❑ Gravel Pack ❑ Tracy Yp g Type of Grout I'1 Public Cl Other Cl Delta Depth of Grout Seal t� I I litigation __Approx. Depth ..l I Eastern Surface Seal Installed by State Work b Repair Work Done El Type of Pump H.P. one , C1 , Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION aNailabpe1within 200 feetstem .) if public sewer is Installation will serve: Residence Commercial,— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:] No. Compartments SEPTIC,TANK ❑ Type/Mfg Capacity - Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property.Line Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED El Distance to nearest: Well Foundation Property Line I SEEPAGE PITS [ I Depth 1 Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line '4 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 favus, and rules and regulations of the San Joaquin Local Health Distiict. 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 fallowing:"1 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." inspections, Complete drawing on reverse side. The applicant must tall for all required pe / _ ;2 ' Title: � ��/ Date: , Signed X FOR DEPARTMENT USE ONLY Date I Application Accepted by Pit or Grout inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Cl Lodi 369-3621 C1 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 CK RECEIVED 1.IVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH k INFO .^� - C _ /rJ� �J//j� /1/ ..EH 13-24 IREV.7/H 51 i''tY s EH 14-28