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APPLICATION FOR PERMIT 4!!E�E SAN JOAQUIN LOCAL HEALTH DISTRICT �� /' 1601 E. HAZEL T ON AVE., STOCKTON, CA Nro U-'x�( fJU__' Telephone (209) 466-6781 / PERMIT EXPIRES 'I YEAR FROM DATE ISSUED ��•�4c �' (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.5"r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / a z l C it "'� Joh address Y Lot Size PMf Owneir's Name Addres Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications 17 Public C] Other Delta Depth of Grout Seal Type of Grout _ I I Irrigation --.Approx. D th I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTFIUCTIOVf4QNo 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 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �SY FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 10 DISPOSAL PONDS ❑ I herebykertify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �l 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 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." The applicant must call for ail required) spections. Complete drawing on reverse side. Signed X J Title: Date:JV R DEPARTMENT USE ONLY J� Application Accepted by C/L t.+� - Date V' " � Are Pit or Grout Inspection by Date Fi spection by, Oa. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ fracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE A OUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO �fASH ♦ EH 13-24IREV.t/H51 / - �"3 / ,�+t / !1/�„ EH 14-26 I' IP7 tJ VIt