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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 DA* 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 made H compliance with San Joaquin County Ordinance No.549 far sewage or No. 1862 for well/pump and the Rules and Regulations of Hie San Joaquin Local Health District. T�application is r � Job Address 1� city Lot Size PM i Owner's Name =+ "Address 3 1 Phone Contracta� ddress .._ ress �J one TYPE OF WELUPUMPLicense No. Ph : NEW WELL ❑ one WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE,TO NEAREST: SEPTIC TANK -, OTHER ❑ SEWER LINES *. DISPOSAL FLD. FOUNDATION PROP. LINE AGRICULTURE WEL'L`S ` - OTHER WECt:• �•: PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIHCATfQNS��r• ❑ Industrial ❑ Open Bottom - 1 ❑ Manteca j -.Uta,.of Well Ek vation"mss Dia, of Well Casing' ❑ Domestic/Private ❑ Gravel Pack� N, ❑ Tracy T -El Public Public _,�L �'�_ -Type of Casing _ Specifications. f ° ❑ Other " u❑ Deli Depth-of Gr'out.Seal' Vy ❑ Irrigation _gpprox. Depth ❑ Eastern .1 Type of Grout M Surface Seal installed Repair Work Done ❑ Type of Pump H. f State..Work•Done _ t Well Destruction ❑ Well•Diameter + Sealing Material (top 50'} r� s Depth - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ISQ s t Installation will serve: Residence available within 200 feet.) Commercial Other Number of living units: Number of bedroom, Character of soii to a depth of 3 feet: SEPTIC TANK ❑ TWater table depth Type/Mfg Capacity L/ PKG. TREATMENT PLT. ❑ No. Compartments Distance to nearest: ' y Method off Disposal Well Foundatiori r_� Property Line 02 LEACHING LINE Cl No. & Length of lines FILTER BED r Total length/size ❑ Distance to nearest: WellV42 C _ x Foundation property Line SEEPAGE PITS ❑ Depth `. Size Number SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS 1:1Foundationv _ property Line__ _ I hereby certify that i have prepared this application and that the work willbe 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 employ any person in such manner as t'o become subject to.workman's compensation laws of California."Contractors hiring asub-contracting lsignaitu�e certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ tion laws of California." g p Y persons subject to workman's compensa The applicant ust call for requir inspections. Complete drawing on reverse sde:� Signed r Title: Date: 'r FOR DEPARTMENT USE ONLY Application Accepted by �J11�� [ Date L Area Pit or Grout Inspection by w Date a Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-W21 ❑ Manteca 823-7104 CI Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20009 Stk., CA 95201 FEE ! INFO AMOUNT DUE AMOUNT MITTED CK CASH RECEIVED BYER 13-24 DATE, PERMIT'NO. +EN 14.28+REV,tia51 O } f