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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 1Tl {Complete,in Triplicate) 9r cation is Application is hereby made to the San Cooa uin Local Ordinance Health District for sewage or emit t 1 on for made in compliance with San JoaquintY well/dpump and the R41es and/or install the work (Regulations of the Sar-'Joaquin . 4 Local Health District. t: `zz,q `1 t PM R-"7��- Q-'` {` _ City Lot Size Job Address o ^a�+ � � Address • � �' �"` � Phone�� Owner's Name , J License No. Phon 6 Z Address y Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION SYSTEM REPAIR 12OTHER EJ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 'Domestic/Private ❑ Gravel Pack Tracy Type of Casing Type of Grout ❑ Public E3 Other Llyp Delta Depth of Grout Seal 1-1Irrigation ----Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '� State Work Done i Well Destruction ❑ Well Diameter r Sealing Material (top 50`1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No ailabPelwithin e200 feetitted if public sewer is Installation wi Residence Commercial— Other ' Number of living units: ber of bedrooms Water table depth n i Character of soil to a depth of 3 feet: Capacity No. Compartments ' SEPTIC TANK L:) Type/Mfg Method of Disposal F PKG. TREATMENT PLT. ❑, i Line #•Distance to nearest: Well Foundation Total length/size LEACHING UNE ❑ No. &'Length of lines Property Line FILTER BED ❑ `Dista_ce.to nearest: Well Foundation Number t SEEPAGE PITS ❑ Depth, - Size `r 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 - r k employ any person in such manner as to become subiect to workman's compensation laws of California." Contractors 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 I for all require ,inspections. Complete drawing on reverse side. -Zr t Signed it, —_ Title: Date: f FOR DEPARTMENT USE ONLY 1( R/1 Date Area ! Application Accepted by — -l�,t-=b Date i Pit or Grout Inspection by Date�.^-- Final Inspection by '¢ y. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7144 ❑ Tracy 835 6385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I CK* RECEIVED By DATE PERMIT"NO, FEE AMOUNT DUE AMOUNT REMITTED CASH INFO k 1,+ _ sf• -1 C>a !. +EH 13-24(REV.1/a 5) S• a EH 14-26