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APPLICATION FOR PERMIT t „ f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !. (Complete in Triplicate! FILI �I �- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described1hts a 13c�tion is pP 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 Health District. I. Job Address C City Lot Size J� Owner's Name t i ® ✓1 G� Address �+/ _ Phone Z r Contractor .S , e � = Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL—,,, PITS/SUMPS --L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom 1-1 Manteca Dia. of Well Excavation Dia. of Well Casing 11 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i Q. ❑ Public C1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I'1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Wel! Diameter Sealing Material-{top 50'1 1i Depth -Filter Material (681aw 501 TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIRIADDITION'I?}`. DESTRUCTION (No septic system permitted it public"sewer is ailable within 200 feet.) Installation will serve: Residence— Commercial Other F� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity, . No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: 'Well Foundation Property Line iI SEEPAGE PITS I i Depth Size Number I SUMPS L1 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. IN Home owner or licensed agent's signature certifias the following: "I certify that in the performance of the work for which this permit is issu!ed, I shall not employ any person in such manner as to become subject to workman's compensation taws 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 workma°n's compensa- tion laws of California." I. The applicant must call for all required in ctions. Complete drawing on reverse side. I , Signed X Title:�/r/+'Lta</✓ /�: Qr ri Zr– Date: If 7 g01 FOR DEPARTMENT USE ONLY D Application Accepted by Date )) Area `` g Pit or Grout Inspection by w�7 /] �7 Date Final Inspection by_ � G�c.(t, Dat II-3 e 0 1 W V�V Y' U{.. s 1 Il Additional Comments; � ,� �cc�- ," C_ y 'VZStk 466-6781 171Lodi -3621 L) Manteca 823-7104 ❑ Tracy 835-6385 I' licant - Return all copias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNOA + EH 3-24(REV. "5f �4. U - � 1 V l �5-7-3S9EH 1l �r