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APPLICATION FOR PERMITS r � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ��J C Y►(L C ��17 ' jp P� LA . Telephone (209) 466-6781 y1^�rn� F PAD&�D CA q� PERMIT EXPIRES 1'YEAR FROM DATE ISSUED'' "C p J] Ile le / [f r l ! f �U T Idn per $' (Complete in Triplicate) , �[ L 1 reby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is nce with San Joaquin County Ordinance No.549 for sewage or No. 186.2 for well/pump and the Rules and Regulations of the San Joaquin y trict. y '�► `r � City Lot Size PM Address Phon Contrac ddress + License No. 6ffe QAC Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ S4_; PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL- LS�SLIM - INTENDED USE^ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial s ❑ Open Bottom ❑ Manteca Dia. of Well Excavation {- Dia. of We11 Casing ❑ Domestic/Private Gravel Pack El Type of Casing Specifications ❑ Public ❑ Other Delta 5k� Depth of Grout Seal Type of Grout ' ❑ Irrigation 2A.;D�Approx. Depth ❑ Easter'n Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump %&M&e&5Ue H.P. State Work Done Well Destr�c_tio�n ❑ Well Diameter Sealing Material (top 50') i1I?Y4i +n Depth Filler Material {gelow 50'1 `� y TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l� PKG. TREATMENT PLT. ❑ Method of Disposal 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 SEEPAGE PITS ❑ Depth Size Number V SUMPS ❑ Distance to nearest: Well Foundation Property Line i. 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 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 folly ing:"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 Ca i . The applicant r all required inspections. Complete drawing on r ver a side. �J "Signed Title: Date: FOR DEPARTMENT USE ONLY ` Application Accepted by Date 71LArea r .7 IRSE0 c y Pit or Grout Inspection by �+ Date / final Inspection by Date` Additional Comments: _ /2" Z,-Z� Amli* I�� ❑ Stk 466-6781 ❑ Lodi 369-31 ❑ Mant 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'N0. r INFO CASH .EH 1324[REV,r/b5l �0 c X44 M �o � � -e 4 EH 14-26 �' �