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��- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r F (Complete in'Triplicate) h` Application is he(eby 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. k Job Address Of City of size PM Owner's N �' A Address Phone i 1 Contra Address cense No:� Phone3W,e5 � TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE 1\ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V� P. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( - ff) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E] Gravel Pack Ll Tracy Type of Casing Specifications F} _ 71 Public Other 171 Delta Depth of Grout Seal Type of Grout l 1 Irrigation —.-Approx. Depth I I Eastern Surface-Seal.Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Al 11 Well Destruction Well Diamete', Sealing Material (top 50'1�, C 12J1rY�_Q Depth Filler Material (Below-50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION L I DESTRUCTION l 1 INo septic system permitted if public sewer is available 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation———Property Line r 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 rules and regulations of the San Joaquin Local Health Di§trict. ' ' 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.:_Contract4m.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 m t cal for al equired inspections. Complete drawing on reverse side. igne Title: Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by ` Date �� / ^�[L Area 6 i Pit or Grout Inspection ate Final Ins Dat d PQ b Y � Inspection b Y Additional Comments: ❑ Stk 466-6781 ❑ k6i 369-3621 Cl Man 823-7104 ❑ Tracy 835-6385`e-t Applicant - Return all copies to: E fironmental ealth Permit/Service 1601 E. Hazeltonn Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOAT REMITTED CASH RECEIVED 9Y DATE PERMIT-NO. r.EH 13.24(REV.t/A 51 �� c]' 73 ,O'D �� EH 1A-26