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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT G 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin E Local Health District..- I Job Address City f Lot Size Owner's !Name ��- Address"- ' 4 Phone Conlractor(� _ - Address icense r�}7/`/ J Phon !/ TYPE OF WELL/PUMP: NEW WELL- WELL REPLACEMENT ❑ -DESTRUCTION_❑ PUMP INSTALLATION STEM REPAIR d ' ='" OTHER ❑" -a l DISTANCE TO NEAREST: SEPTIC TANK, . 007-1- SEWER LINES DISPOSAL`FLDA S-0 PROP. LINE _f ° FOUNDATION AGRICULTURE WELL OTHER WELL —PITS7SlJMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r mestic/Private ❑ Gravel Pack L3 Tracy Type of Casing Specifications .�„�� k M Public ❑ Other CI Delta Depth of Grout Seal ! Type of'Grou + t I I Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by - 1 T� Repair Work Done ❑ Type of Pump H.P. �-- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 _ ` Depth - _–—Filler_Material_(,Below_50') TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION [I DESTRUCTION i I (No septic system permitted iE,public�sewer is available within 200 feet:! y+: 'k s t Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: - t *` Water fable depth l SEPTIC TANK ❑ Type/Mfg Capacity No..,Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal d Distance to nearest: Well Foundation '^y Property.Line ' LEACHING LINE ❑ No. & Length of lines -t Total length/size FILTER BED ❑ Distance to nearest: Well _ ✓ Foundation Property Line s SEEPAGE PITS 1.,l Depth. Size Number f SUMPS 0 r'Distance tofnearels;st: Well Foundation Property Line DISPOSAL PONDS ❑ - F � 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. r I 1 Home owner or licensed agent's signature certifies the following: "l 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 compansa- I tion laws of California." r The applicant mus call for all required inspections. to drawinon-reverse side. Signed X Title: iL - _ Date: FOR DEPARTMENT USE ONLY Application Accepted by '`.Date y Area I Pit or Grout Inspecti n Date ° - Final inspection y.. L � Data b � f Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r :Si FEE AMOUNT DUE AMOUNT REMITTED CA REC IVSD BY DATE PERMIT'NO, e INFO +.EH13-24(REV,I R51 F t%� � f Q•�� Q71�( L�jf/� C7 1. EH 14-26 W . f