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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZEL T ON AVE., STOCKTON, CA" . Telephone (20) 466-6751 IqRb PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PMG 2 1; (Complete in Triplicate) I "�^1. Yl`-' , EN`A Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the p�Cj�b ��h aflplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules i ns o the San Joaquin Local Health District. - t Job Address 0 F CityC_ / t ti Lot Size Owner's Name Address Phone 1 �'°AA Contractor Address �� i License No. 6 L Phone TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Dt_51HUt;IJUN u PUMP INSTALLATION,)iVQf�anLL*tl�)SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .INTENDED USE ❑ Industrial )oDomestic/Private M Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other Cl Delta Depth of Grout Seal --Approx. DepthI pI Eastern urface Seal Installed by Type of Pump _ _._,11� H.P. – State Work Done _ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') 'PE OF SEPTIC WORK: NEW INSTALLA Dia. of Well Casing Specifications Type of Grout N I 1 REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence —, Commercial — Number of.living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK ❑ . Type/Mfg PKG. TREATMENT PLT. ❑ Other Water table depth_ Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Method of Disposal Property Line Total length/size_ Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." 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 California." The applicant r all re ctions. Complete drawing on rave a side. Signed X _ Title: Date: EPART T USEON Application Accepted by Date yy `!� Area �S . Pit or Grout Inspection by Date Final Inspection by /t— _ Date G7L' ( d Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY PATE PERMIT NO. +. EH 13-24 1REV. ibW EH 1,_29