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t ! APPLICATION FOR PERMIT SAN 30AQE3IN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 wellt-pump and the Rules and Regulations of the San Joaquin Local Health District, 1r 3 '° �'��n tib �: tX City Job Address Lot Size PM l Owner's Hama Address 7 �- Phon 's",�J 71 — Contractor [wi✓►•1. Address Z�Z �• ' License No. Zu0 Ph,, 2 ; TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1@: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FO NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 in ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i� ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing S[.i, A Specifications .i. * Public t Ll Other F1 Delta Depth of Grout Seal Type of Grout s I Irrigation, 5'0 Approx. Depth I l Eastern Surface Seal Installed by - Repair Work Done ❑ Typ of Pump H.P. State Work Done W 11 Destruction ❑ Well Diameter Sealing Material (top 501 ` c W pep�th Filler Material (Below 50'i TYPE OF S P C WORK: NE`W INSTALLATION (1 REPAIR/ADDITION t I DESTRUCTION t I (No septic system-permitted if public sewer is I it available within 200 feet.) Installation will serve: Residence' Commercial Commercial_ Other II' Number of living units: Number of bedrooms Character of soil to a depth sof 3 feet: Water table depth h SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Edo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line JI. SEEPAGE PITS f I Depth Size Number 1r SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI III! I 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. 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 Calif nia." I: The applicant u t call for all req ired " spections. C plate drawing on ve se side. G� Signed X y I Title: �� Date: Z/ FOR DEPARTMENT USE ONLY Application Accepted by Date Af Area Pit o Grout I spection by L Date Final Inspection by 1ei AN - Date j Additional Comments: I - v C 262 TF C ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k"' T Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMIT-TEDT'CASH RECEIVED BY DATE PERMINO" Ih a FI 13-24IREV.I i x 51 l � � 1 rs- 97 J 0 EH t4-2a