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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Health 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City c %% __ Lot Size/Y xt�®%� PM Owner's Name `.Addresses /�� Z� Phone � Contractor's Name ,&- ys OA/a License No. .:7-f—V "<7yj Phone !&- G " TYPE OF WELL/PUMP: # NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �-IS• a�-:� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigate' n __4pprox. Depth ❑ 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 _51ler_Material_(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Iavailable within 200 Installation will serve: t� Residence _ Commercial --feet.) i Other Number of living units: A. Number of bedrooms. i Character of to depth 3 feet: J1!9A,-A?.V, soil a of _r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines . Lj ' Total length/size 6,9 FILTER .BED � Distance to nearest: Well 41--9 Foundation ZC?1' Property Line 20 � f. SEEPAGEPITS ❑ Depth Size j }•,- Number' _ SUMPS p ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 1 hereby certify that 1 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. r of 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." Contractors 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." t The applicant st call for all required Inspec Sons. Complete drawing on reverse side. Signed Title: Date: 2 Z_:�, FOR•-DEPARTMENT"USE-ONLY Application Accepted byDate Z_ -Area Pit or Grout Inspection by Date Final Inspection by `� Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy., 835,6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.' Hazelton'Ave.,'P.O. Box 2009, Stk., CA 95201 + EH 1324 (REV. 101831 EH 1426 FEE INFO AMOUNT DUE_ - -- AMOUNT REMITTED CK CASH— RECEIVED BY _ DATE PERMIT"N0. �-IS• a�-:� � � �..._ _ . 9- '1 gtl -ill