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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 466-6781 PERMIT EXPIRES 1'YEAR 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 with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. • I - ob Address �_ City lot Size PM /bl tel`r" ' �ness AddressPhon ner's Name _�Contractor RLicense fto, Phone_ k TYPE OF WELL/PUMP:. _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION If PUMP INSTALLATION SYSTEM REPAIR C] OTHER I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ©Manteca Dia. of Well Excavation Dia. of Well Casing 1 Type of Casing Specifications r r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy g V r (-I Public F1 Other C1 Delta Depth of Grout Seal Type of Grout n Depth I 1 Eastern Surface Seal Installed by - ! I Irrigation —,App(o)k. l/ 1 Repair Work Done ❑ Type of Pump H•P. S to W k Done O e + _ _—�— Well Destruction Well Diamete Sealing Material (top 50') Depth ' Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRIADDITION t l DESTRUCTION [ I {No septic system permitted if public sewer is available within 200 feet.) t Installation wl Residence Commercial_ Other Number of living units: umber of bedrooms -� Character of soil to a depth of 3 feet: t e depth SEPTIC TANK ElType/Mfg ' No. Compartments PKG. TREATMENT PET. ❑ t Method of Disposal Di nearest: Well undation Property Line 1 ` LEACHING ❑ No. & Length of lines otal length/size FILTE ED ❑ Distance to nearest: ' Well Foundation operty Line I � SEEPAG ITS i I Depth Size Number h SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I 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 a�er, n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifi , the folio ing: "1 certify that iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's Compensa- tion ws^t5f a rnia." The ppticant st call far ail requir d inspections. Comple rawing on } erse side. Sig \� Date: , f t PARTMENT USE ONLY ` Application Accepted by Date Area d j Pit or Grout Inspection by Date �` ° Final inspection by Date t Additional Comments: "0 � u ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca A23-7104 CYT, Wy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT D IE AMOUNT 7REMITTED CK RECEIVED BY DATE PERMIT NO. i, FEECASH INFAl O+ EH 13-24(REV.t/H 51 �� 3 �, L�'1/✓ /� v � EH 1428