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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 (Complete in Triplicate).. all the work Application is hoieby made to the San Coun cation is ui Ordinalncle No.549 for sewage or ealth District for a permitNo. 1862 for cwellldpump and the Rules and IR Regulations of tlhe San is l Joaquin made in compliance with San Joaquin 7 County Local Health District. r City Lot Size PM Job Address I Address Phone i Owner's Name �/ ` 4 c'! Licens Phor 4 Contractor Address r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll REPAIR 17 OTHER ❑ ` SEWER LINES DISPOSAL FLD. PRD i DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION-- AGRICULTURE-WELL - - —OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S ATIONS Dia. of Well Casing Q Industrial ❑ Open Bottom ❑ Manteca Dia�Wxcavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy \ ❑ De Depth of Grout Seal Type of Grout fl Public f 1 Other - - Approx. D I Eastern Surface Seal installed by I 1 Irrigation — State Work Done_ Repair Work Done L3 ump H.P. Well Destru El Welt Diameter Sealing Material (top 50'I h, Depth Filler Material (Below 501 STALLA.TIO_ N l 1. REPAIRlApDITION l i DESTRUCTIO INo septic system permitted it public sewer is �._. --� --available within 200 feet.) I TYPE`OF'SEPTiC-WORIC:�=NEW-1 \ t tOther Installation will serve: Residence Commercial Number of living units: Number of bedrooms LV, Water table depth , Character o1 soil to a depth of 3 feet. ( No. Compartments I SEPTIC TANK ❑ Type/Mfg Capacity } --`' Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line v Total length/size LEACHING LINE Ll No. &Length o1 lines FILTER BED O Distance to nearest: Well Founda"tion• Property Line 'I Size Number SEEPAGE PITS i I Depth SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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. l Home owner or licensed agent's signature certifies the following: "I certify that in tate performance of the wok 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." Contractors 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 applica must call for all required inspections. Complete drawing on rover side. o/ 1 1. ` f, d Title: Date: Sign FOR DEPARTMENT USE ONLY LA,ea j Application Accepted by I Date Date Final Inspection by Date Pit or Grout Inspection by r Additional Comments: �f ❑ Stk 466-6781 ❑ Lo 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 FEE CK RECEIVED By DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH INFO ♦.EH 13-24 iREV.t/n 51 3 �✓ �� Q - EH 14.28