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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE i ON AVE., STOCKTON, CA -1� Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit-to construct and/or install the work herein described. This application is f 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. p I Job Address CA City �PIPUti r9 ' - �._ Lot Size PM I Owner's Name Address Phone Contractor dress S- icense No.�r2,/2::C2_Piton,' — TYPE OF WELL/PUMP: NEW WELL'S WELL REPLACEMENT Tg DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK 1�G � SEWER LINES DISP SAL FLD,�%PROP. LINE FOUNDATION AGRICULTURE WELL WELL_2E -. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation2 s Dia. of Well Casing >3.Domestic/Private WGravel Pack 0-Tracy Type of Casing i'i Public Specifications' ❑ Other ❑ Delta Depth of Grout Seal I I Irrigation Type of Grout J /�..Approx. Depth (�t'fastern Surface Seal installed by f Repair Work Done ❑ Type of Pump H.P. tai Wor Well Destruction ❑ Well Diameter Sealing Material {top Depth Filler Material (Below 50'I j 7 TYPE OF SEPTIC WORK: NEW INSTALLATION I_i REPAIft1ADDITION ! I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercials .Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I SEPTIC TANKWater table depth ❑ Type/Mfg Capacity t PKG. TREATMENT PLT. ❑ No. Compartments a 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 � r 4 SEEPAGE PITS i I Depth Size SUMPS Number ❑ Distance to nearest: Well FoundationProperty Line 1 DISPOSAL PONDS ❑ F I hereby certify that I have prepared this application and that the work will be doini in accordance with San Joaquin county ordinances, state l rules and regulations of the San Joaquin Local Health District. aws, an Home owner or licensed agent's signature certifies the following: "I certify that,in the employ any person in such manner as to become subject to workman's compensation laws of California." Contractor sthuingl oPsub�cont shall certifies the following: "I certifythat in the Performance of the work for which this permit is issued, I shall em to P tion laws of California." p y persons subject to workman's compensa- The applicant st c f all raq 'r inspections. Complete drawing on r rse side Signed X t Title: Date: TAAENT US NLY Applica ion Accepted by Q t 9 Date Area ` P' r Grout Inspection by bate Finp Y �(} al section b Date Addaiana omments: �'-'`U �' r ❑ 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 95201 FEE MOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMrI�T N�OJ"/'j �.EH 13-24 IREV. i K 51 r 0� j/r-M / EH 14-2f1 t.-(� _ -