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APPLICATION FOR PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Q,0 �� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'. . 4* (Complete in Triplicate), *t *--,rs. 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 alth District. VC J' [JobAddress City Lot Size PM110 er's Name5i � Address_f Phone tractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � THER ❑ DISTANCE TO NEAREST: SEPTI SEWER LINES DIS LD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL RE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M a Dia. of Well Excavation - Dia. of Well Casing . ❑ Domestic/Private n Gravel Pack Tracy Typ Casing Specifications ❑ Public [I Other Delta" " Depth of Gro ea'aI � � 7 Type of Grout ❑ Irrigation •4 ,,. prox. Depth ❑ Eastern Surface Seal Installed J Repair Work Done ❑ Type of Pump H.P. State Done I4 Well Destruction ❑ Well Diameter R N 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.) Installation will serve: Residence Commercial Other k Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' { ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS! ❑ Depth Size r Number SUMPS - ❑ 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 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 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 applic nt must all for all require 'actions..9;�,Complete drawing on reverse side. Signed , Title: /�I 11 /Vl _ Date: DEPARTMENT USE ONLY 1 Application Accepted by Date Area Pit�or Grout Inspection by iDate Final inspection by Date �Z Additional Comments: V�AJ4�� I f - ❑ Stk 466-67816385 Lodi 369-3621 ❑.Manteca 823-7104 ..O Tracy 935-6385 h Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t s FEE -AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. I INFO '+ EH 13-24(REV.1.e 5) EH 14-28 - - 1 --