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I �D APPLICATION FOR PERMIT I t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) . This cation is Application is he+eby made to the aJoaquin QLoc Ordealth 0inance No. 549 for sewage or permit No 1862 for cwell/pump at and/or nd the Runes and Regulationll the vvork herein s of he San{Joaquin made in compliance with San Joaquint1 Local Health District. .. City ! Lot Size PM Job Address r----- RPhone 4 d ress Owner's Name Contractor Address License No. �Phone TYPE OF WELLIPUMP: EW WELL WELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1-1 Industrial / pia. of Well Casing Type of Specifications �� -«❑ Domestic/Private ❑ Gravel Pack C] Tracy Casing Public C� (.l Other ❑ Delta Depth of Grout Seal ` Type of Grout — i-I Irrigation j .. nv Approx. Depth l I Eastern Surface Seal Installed by Jam Repair Work Done ' Type of Pump .�ldX�_..--- H•P• .a State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Dept Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION l I ('No septic system permitted if public sewer is �\ v available within 200 feet.) Installation will serve: Residence Commercial, Other ^ Number of living units: Number of bedrooms �3 Character of soil to a depth of 3 feet: Water table depth �v 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 r: Number SEEPAGE PITS 11 Depth Size 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. Home owner or licensed agent's signature certifies the following: "! certify that in the performance of the work for which this permit is issued, ! 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 applicant must cal r all red ins c' ns. omplete drawing on reverse side. `signed X (�\ Title: Date: FOR DEPARTMENT SE ONLY Date �'" Area , Application Accepted by 1 ¢ Com" Data .. Final Inspection by Date Pit or Grout Inspection by Additional Comments-0 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.O. Box 2009, Stk., CA 95241 FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTER CASH a EH 13-24 IflEV.1/n 51 EH 14-26