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APPLICATION FOR PERMIT SAN JOAQUINI� �LOCAL HEALTH DISTRICT f 1601 E. HAZELfiON AVE., STOCKTON, CA l Telep one (209) 466-6781 PERMIT EXPIRE 1 YEAR FROM DATE ISSUED (CoY plete in Triplicate) Application is hereby made to the San Joaquin Local Health Distric 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 f sewage or No. 1862 for well/pump and the Rules and Regulations of the an Joaqui Local.Health District. r 70S`X Z 4.0 PM �• Job Address -3 tJ / a� L� 4� City Lot Size, T f Owner's Name4 � Address d`'�e/ Phone Contractor's Name i f License o. f ` Phone 3' TYPE OF WELL/PUMP: NEW WELL NELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _,._-_ SEWER LINES DISPOSAL FLD. PROP. LINE f� FOUNDATION 0 AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J/ . .. ' ❑ Industrial ❑ Open Bottom ❑ Manteca { Dia. of Well Excavation Dia. of Well .Casing y '< Domestic/Private Gravel Pack ❑ Tracy Type of Casing I" V C r SpecificationsCld.-5-S ❑ Public',/ ❑ Other ❑ Delta Depth of Grout Seal O Typ of Grout j mal ❑ Irrigation 2-M--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ^LL,4, H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Oth r Number of living units:. 'Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK w ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _`T, , ,t Method of Disposal + Distance to nearest:.-Well. k Foundation Property Line I LEACHING LINE El No'& Length of lines:- Total length/size y 1 FILTER BED4 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS - ❑ Depth Size Number SUMPS-_-. Cl Distance to nearest: Well Foundation Property Line S 'S DISPOSAL POND1 F-1: hereby certify that I have prepared this application and that the Mvork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1, 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." Contractoes 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 ust c II for all req ed inspections. Complete drawing on reverse side. Signed Ti le: Date: i i F FORDEPARTMENT USE ONLY t Application Accepted.by vv Date ! Area - II Pit o rout spection by 92Late lFinal Inspection by Date 1,0-- v' ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237104 El Tracy 835-6385 kApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 9 DATE PERMIT'NO. + EH 1324 I REV-70193) U Q ¢ 3 [ I's/ r�'�'^ Ps--//3/