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�LLr cFTc APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Jo n o.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Cow Ordinance N Local Health District. �� ri r (�—,7 -Q- ' C/ V1_ City L��' Lot Size PM Job Address n / Phone Owner's Name Address If Contractor C� Address TGA License No.�� hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -❑ """' w,. SYSTEM REPAIR-n '"""""!' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK M. ,. SEWER .LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well.Casing ❑ Industrial C3Open Bottom ❑ Manteca_r Dia.-of Well Excavation T f CasingSpecifications 11 Domestic/ ElGravel Pack El Tracy yp e oType of Grout f'1 Public (7 Other ❑ Delta" Depth of Grout Seal I I Irrigation __-Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filier Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 411 DESTRUCTION (No sbPel systeithinm00 emitted if public sewer is avaInstallation will serve: Residence Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil�to-a"depth-of:3 feet:. y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ M ,i ethod of Disposal l Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size— Well fFoundation Property Line FILTER BED ❑ Distance to nearest: SEEPAGE PITS l I Depth Size ^umber SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ t and that the work will be done in-,accordance with San Joaquin county ordinances, sta I hereby certify that I have prepared this applicationte taws, 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,l shall employ persons subject to workman's compensa- tion laws of The applicant must call f all re ired inspections. Complete drawing on reverse side. lye � Title: Date: Signed X + FOR DEPARTMENT USE ONLY r l 2 Area f 3 Application Accepted by DateQ Pit or Grout dnspection by Date Ilnspectio y Date Additional Comments: D 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.D. Box 2009, Stk., CA 95201 FEE AMQUNT_P.VE._�, _ AMOUNT REfuI4TTER-. �„ RECEIVED BY,w _ DATE • . - CASH - 4 _ ._ ."""" . . A - - +.EH13-24INEV.I/n5r EH 14-2a J i