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s.� r� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE4TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 Local Health District. .�I Job Address City �l9ot Size PM Owner's Name Address P _ Phone 7 '.S1` rr2 3 Contractor's Name In No. � I Phone TYPE OF WELL/PUMP: ,�� f NEW WELL f WELL REPLACtMENT-f7 DESTRUCTION ❑ I PLfMP INSTALLATION ❑ SYSTEM REPAIR ❑- f } Fl. , OTHER ❑ 21 DIST'ANCETO-NEAREST:'SEPTIC'TANKr '!:"" ;-SEWER-LINES DISPOSAL FLO._ -PROP'.' LINE ` FOUNDATION T�=r -'A:GRICUCTURE-1i (FL -L- -- = OTHER'WELLtm--`^PITS/SUMPS _ INTENDED USE ❑ Industrial w: omestic/Private ❑ Public O1rtigation Repair Work Done ❑ Well Destruction ❑ t TYPE OF WELL 'PROBLEM AREA ',moo I ottom ❑Manteca 'k. 3 r EJ Gravel Pack ❑ Tracy ❑ Other C7 Delta ---4pprox _Depth a ❑ Eastern Type of Pump q H•P• Well Diameter 'k Sealing Depth Filler M CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Type of Casing Depth of Grout Seal Surface Seal Installed by'� .{ _-- State Work Done _ MI) Dia. of Well Casing s / Specifications '14Do Type of Grout X7 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [3,:'_DESTRUC-TIOWD_ {No septic system permitted if public sewer is v"" available within 200 feet.) Installation will serve: Residence Commercial"—Other _..— Number of living units: Number of bedraofims Water table depth Character of soil to a depth of 3 feet:' x SEPTIC TANK ❑ Type/Mfgk Capacity— No. Compartments PKG. TREATMENT PLT. ❑ I ` Method of Disposal Distance to nearest: Well , Foundation Property Line ' I IV LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Total length/size_ Property Line SEEPAGE PITS ❑ Depth Size Number -:�-:= SUMP$- � = �^ '❑'Distance to nearest' '�Well ' - "Foundation 2_- `"` - Property Line' - DISPOSAL PONDS ❑ 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 0 rules and regulations of the San Joaquin Local Health District. 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 Californ' The applicant mu re fired ' ctions. Complete drawing on reverse side. 1 Signed Title: Date: } FOR DEPARTMENT -USE ONLY Application Accepted by / Date 'Area;" Pito Gr t Inspection by Date ( ' Final Inspection by� *Date us Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 it Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P'.O. Boz 2009, Stk., CA 95201 +"EH 1324 (REV. 10183 EH 1428 FEE AMOUNT DUE INFO AMOUNT REMITTEDCK • CASH RECEIVED BY DATE PERMIT'NO.