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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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. Job Address c3 City Lot Size M Owner's Name ,{ Address Phone Contractor 7S21ddress License No.Z29`&S/ Phone& TYPE OF WELL/PUMP: NEW VVELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION r SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._k&g PROP. LINE �0 r FOUNDATION 3 AGRICULTURE WELL OTHER WELL PITS/SUMPS �d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1-1 Manteca Dia- of Well Excavation Dia. of Well Casing k.pomesticl Private l�{ravel Pack ❑ Tracy Type of Casing E)_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _�Q,z Type of Grout dEPJ M,fJ ----- ❑ irrigation --Approx. Depth ' El Eastern y Surface Seal Installed by r 't Repair Work Done [ITypeType of Pump �y�gt H.PTL . Sta Wofk Done �f�1 Well Destruction ❑ Well Diam r r � ( Sealing Material (top 501) Zpth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INS ALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.) 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines E t Tota! length/size' FILTER BED ❑ .Distance to nearest: Weil FoUhdation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well. w+ Foundation Property Line DISPOSAL PONDS ❑ 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." , The applicant em 04S rcall for all required inspections. Complet awing on reverse side. Signed X Title: Date: OF FOR DEPARTMENT USE ONLY J Application Accepted by j� Q Date Z Area Pit or Grout Inspection by !� ~ ate _/t/ Final Inspection by Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 D(Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Service* 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FTED INFO EE AMOUNT DUE AMOUNT REMITC _RECEIVED BY DATE PERMIT'NO. + EH1 -24{REV.fiHs) . `�. .. � EH 1428 l ! 0