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APPLICATION FOR PERMIT �s - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA NoW Telephone (209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N'S (Complete in TriplicateT7 * „ Application is hereby made to the San Joaquin Local Health District for a� e� i o construes @,d "-�'- P ar a/or install the work herein described:This applicat+on is made in compliance with San Joaquin County Ordinance No.549 for sewage.or No q for well/pump and the Rules and.Regulations of the Sart Joaquin Local Health District. tt tw y k. Job Address 1 f �I City 54 1 Lot Size PM q Owner's Name Phone A1� .-9ys� Contractor's Name _rose No. _ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ " 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 A ❑ 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 ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler'Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT DESTRUCTION {No septic system permitted if public sewer is ' �. vailable within 200 feet.) Installation will serve: Residence� Commercial }.-Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg' Capacity-=.-- No. Compartments PKG. TREATMENT PLT. ❑ FI Method of Disposal � Distance to nearest: Well Foundation Property Line1 r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS , ❑# Depth Size Number # II SUMPS ❑' Distance toynearest: Well 4 ~Foundation Property Line k DISPOSAL PONDS ❑ p 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: '9 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." k - The applicant m inspections. Complete drawing o reverse side. / p Signed X Al Title: % Date: a x F DEPARTMENT USE ONLY Application Accepted by Data Area �d Pit or Grout Inspection by Date- - Final Inspection by Date le Additional Comments; lora y d ❑-Stlk 466-6781 ❑ Lodi 360-3621 O Manteca 823-7104 -❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE F'7 IT"NO. +EH 13-24 iREV.10183} �.� - Or,/_ 17EH 1426 !CO O/ �