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'I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 �� v ` City Lot Size 5.� 1� 1 PM Owner's Name ,�N U- r- _ Address 2 � � // _ Phone .(D Contractor Address TYPE OF WELL/PUMP: NEW WELL C7 License No. Phone_ - WELL REPLACEMENT LJDESTRUCTION EJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dra. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing Specifications i-) Public ❑ Other ❑ Delta Depth of Grout Seal I I irrigationA Type of Grout pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P. State Work Done - Well Destruction C2 Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 1J TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION I '1 DESTRUCTIO Wo septic system permitted if public sewer is I1i1? Installation will serve: Residence_ Commercial.� Other available within 200 feet.) Vfy✓ Number of living units: Number of bedrooms V j Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit P y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1Distanceto nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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, f 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 I 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 all required inspections. Complete drawing on reverse side. Signed X Title: �& — 1- Date: DEPARTMENT USE ONLY Application Accepted by —_ / _ Date Area Pit or Grout Inspection by Data 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 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT•No• + EH 14-24 IpEY.1/"5) �/"�CT ��^®C:2 14Q, f