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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein described. This application is 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. Job Address / G City Lot Size r PM Owner's Name 1 i• � Address ! L(/ � Phone / C� m Contractor Address License No. Phone f TYPE OF WELL/PUMP: NEW WELL. C] WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP-INSTALLATION (8 - SYSTEM REPAIR.❑ .. OTHER,❑ - DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS wd ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W"Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public L1 Other I ❑ Delta Depth of Grout Seal Type of Grout --- 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 (top 50') \\\\ Depth Filler Material /Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION f I (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 of3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments, PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED El Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS i I Dept_h Size 'y r Number t 1 SUMPS Ll - Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 # 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. f 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, I shall employ persons subject to workman's compensa- tion laws of California." „1 The applicant call for all requir din ctio Complete drawing on reverse side. ' Signed X �JrTitle: Date: EPARTMENT USE ONLY CQJa t Application _Accepted by Date "�" L Area Pit or Grout Inspection by Date Final Inspection by Date �- - 6-4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 UKRY FEE INFO AMOUNT DUE'1 AMOUNT REMITTED CASH RECEIVED BY DATE �}pPERMIT'NNO. +.EH 13-24/REV.t i n sl 3 5 ��( S i {J �`� "7 EH 14-20 V -/