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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _. 1601 E. HAZELTON AVE., STOCKTON, CA - Telephone 1209) 466-6781 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 wit Joaquin Coun Ordin n e o r sews or o. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.WAR— r �j�v[ i 1 Jdb Address -tz Cit Lot Size PM wt'llom I!Owner's Name Address o .-._.._ Phone , I� 1Corltractor Address License No. Phone_ I PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO"' iM PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 I , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE I� FOUNDATION - - AGRICULTURE WELL WELL PITS/SUMPS _ IJ. Ij INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ON SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing I❑ Domestic/Private ❑ Gravel-Pack - ❑ Tracy Type of Casing Specifications i 11-7 Public �`. ❑ Other CID Depth of Grout Seal F Type of Grout rI Irrigation \�'� --Approx. Depth Eastern — Surface Seal Installed'by k Repair Work Done ❑Type of Pum H.P. State Work Done Well Destruction ❑ Well Dia ete� Sealing Material (top 501 I� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION ,I (No septic system permitted if public sewer is `\available within 200 feet.I (� Installation will serve: Residence_ Commercial_ Other ' Number of living units: Number of bedrooms u Character of sail to a depth of 3 feet: Water table depth 'J SEPTIC TANK ❑ Type/Mfg Capacity -NorCompartments s PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line I I 4 !LEACHING LINE ❑ No. & Length of lines Total length/size M FILTER BED ❑ Distance to neatest: Well Foundation Property Line l�SEEPAGE PITS i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ;DISPOSAL PONDS ❑ jl 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: "1 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." E�The applicant�/m�'�usGrailreqiredins cY�� Complete drawing on reverse side. ,p Date:Signed X-, Title: ' FOR DEPARTMENT USE ONLY €Application Accepted by r ^� f /i��-� -� Date Pit or Grout Inspection by Date Inspection y �^ Date 212--a--l. . 1�Additional Comments: OU 3 �!❑ 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'20M, Stk,,-CA 9520FEEJ 1 \� INFO OUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. a EH 13-28(REV.1 i K 5) EH 14-28 / (,,.� ! 3�,�(� ✓✓✓ it