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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 incompliance 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 AddressIq City Lot Size PM Owner's Name tddr's' Phone Contractor's Name icense No. Phone TYPE OF WELL/PUMP: NEW WELL EY WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustrial 171 Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation i --Approx._Q229L, ❑Aastern - —Su face Seal Installed by Repair Work Done ClType of Pump -'�'p�A1•P• State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 .Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) • b - Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms > Character of soil to.:-a depth of 3 feet: - Water table depth I SEPTIC TANK - 0 Type/Mfg r'- Capacity No. Compartments PKG._ TREATMENT PLT:'❑ Method of Disposal Distance to nearest: )Wall Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total.length/size 5'[,,],`]i FILTER BED ❑ Distance to nearest: Well Foundation--_ Property Line f,SEEPAGE PITS ElDepth Size Number SUMPS ` ❑ Distance to nearest: Well 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: "I 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 at in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The appli_a t must I for required ins e e rowing on rev mid Signed Title: Date: FOR DEP TMENT USE ONLY W Date "01' Area +� Applicatio "pt, by Date Final Inspection by - ?-1 1 'Pit or Grout Inspection by ' Date Additional Comments: lT LJStk 466-6781 [1Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355'6385 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 CK 4 CASH RECEIVED BY DATE PERMIT`NO. INFO } G + EH 13-241REV.101831 �� _ �.�,:> b ` 'V /i? g 71-