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b" � APPLICATION FOR PERMIT ;s ,< SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E:JIAZELT ON,AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 j 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. - f J Job Address �' ty ize PM Owner's Name >M,4�tldress Phone Contractor Address License No. Phone p _ f TYPE OF WELL/PUMP: ffEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j f `t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 11 Ind lal � ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I m R ❑ Public � 71 Other ❑ Delta .. Depth of Grout Seal Type of Grout ❑ Irrigation �+`/ pprox. Depth ❑ Ea ern+ Su ale eal I tailed by h" Repair Work Done ":�r�Type of Pump;_-�� H.P. State Work Done j Well Destruction E:]?k Well Diameter Sealing Material (top 501 �f 1 1:)Depth- "f. �+ I Filler Material(Below 501 J d ,TYPE-OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is F available within 200 feet.) ' 1 t _ Installation will 'serve: Residence FJ Commercial_� Other ' Number'of living units Number of bedrooms Character of.soil to a depth of 3 feet: Water table depth SEPTIC TANK LlType/Mfg_ v+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method-of Disposal ' Distance to nearest: Well Foundation Property Line l LEACHING LINE.` ❑ No. & Length of lines Tota! length/size FILTER BED ` - LJDistance to nearest: Well Foundation Property Trine "A41. �- , SEEPAGE PITS le-. �4'� ❑� Depth Size Number � ) SUMPS y u ❑ DistsnXt'to nearest: Well Foundation Property Line i DISPOSAL POND81r �` 1 I hereby certify` t l'h`ave pr ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1, rules and re ations of the S Joaquin Local Heal )strict. Home ovri r or'licensed.agen s signature certifies a ollowing: " at in the performance of the work for which this permit is issued, I shall not employ y person in such nner as to m ub' ct to r t an's compensation laws of California."Contractor's hiring or sub contracting signature l certifie the following: " ify th tin rf m ce of ork for 1whichthis-permitis iss e 1 shall employ persons subject to workman's compensa- tion I s of C The plicant mu r I qwr s ns. Co pieta drawing Si ned "f Title: Date F �EPARTMENT USE ONLY ' n Acce t ed Date � Area 6 Application PP ,P �'. - 2 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.5155) / rs-7 EH 14-28