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APPLICATION FOR PERMIT t SAN JOAQUiN LOCAL HEALTH DISTRICT 1601.E. HAZELTON AVE., STOCKTON CA ,� Telephone (209) 466-6781 r~ ,irk � 9' b-U2.q Ga " . PERMIT EXPIRES 1 YEAR FROM DATEf ISSUED Ll:o : ��5�"S3S2 �0;►.i Y.,. (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 made in compliance with San Joaquin.County Ordinance No.549 fo wa a or No. Imp, #or Local Health'District. �y, PPi on is �!J {'do- pump and the Rules and Regulations of the San Joaquin Job Address g7 City Lot Size PM Owner's Name` - _ ` Address .. � '� � j Phone Contractor_ J l G � Address �e TYPE OF WELL/PUMP: License No. Phone (J NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL_ PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom_ ❑ Manteca - + Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ❑ Public Type of Casing_ Specifications y ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation', Depth ❑ Eastern TYpE of Grout Repair Work Done t ❑ Type A Pump Surface Seal Installed by - Type State Work Done Well Destruction � ❑ Well Diameter: Sealing Material (top 50'1 A Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIA/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence - available within 200 feet.) Commercial_ Other Number of living units: 4— Number of bedrooms . -� Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg ` 4 '"' Water table depth PKG. TREATMENT PLT. ❑ i Capacity ]No. Compartments i` Method of Di ..v Distance to nearest: Well�[✓� Foundation ~^ Property Line �sg�osai — LEACHING LINE No. & Length of lines" FILTER BEDTotal length/size ❑ Distance to nearest: Well - Foundation _ Property Line 7A-6- _, SEEPAGE PITS r '! ,� � Depth ._, r •• � �` -.� ^.� , ❑ Distance tone,.,. � `mbar . ' 1SPwell! L�� Foundation bCi5AL PONDS '�❑. r 4 Property Line 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 District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shad 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 tion laws of California:" p y persons subject to workman's com ' ' pensa- The applicant must call for all , 'red inspections. Co plete drawing on averse side. f 1 Signed Title: tS�� ' f s Date: FO DEPARTMENT USE ONLY Application Accepted.by ' _ Date '�� res Pit r Grout Inspection by ��}��/ ' _ Date--�Final Inspection by r —8 Additional Comments: Date ❑ Stk 456-6761 ° . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ' ❑ Tracy 83&.638.5 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMEDUEAMOUNT REMITTED CK INFOCASH RECEIVED BY DATE PERMIT'Np. r EH 13-21 fREV.i/857 _ EH 1429