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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 "' Application'1s hera6y made to the San Joaquin Local'Health District for a permit to construct and/or the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we lllpump and the Rules and Regulations of the San Joaquin Local Health District. 1/ ' Job Address City�rGKTDI✓ Lot Size PM Owner's Name � � !VAIf I Address a �"� 4 all, 0-O A - Phone Contractor's Nam R S 7-40zt-i ansa No. 4& 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL gyREPLACEMENT ❑ DESTRUCTION E-1PUMP INSTALLATION'X,&,p C CEM�N TEM El REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom [❑ Manteca Dia. of Well Excavation Dia. of Well Casing { 7Domestic/Private C1 Gravel Pack LI Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dept ❑ Eastern Surface Seal Installed by ,r Repair Work Done El Type of Pumps H.P. i f State Work Dane f h' Well-Destruction-0, Well Dialnete-r"'"°""-�`' _' Sealing-Materialltop'509'�""�"�''" yi k Depth Filler Material (Below 50') -^r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systemVeirrrtted-if`public sewer is W •� � 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 V 13Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation• Property Line Af ri LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Al SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 C' 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 o`f Cal'rfomia."Co tractor's Hiring orsu�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 Cal' nia." The applicant st call f roll r q inspections. Co plate drawing_orlj Signed Title: �TIQ� Date: FOR DEPART T USE ONLY Application Accepted by lam✓ Date Area Pit or Grout Inspection by Date Final Inspectlon by Date if 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 AMOUNT DUE AMOUNT REMITTED I CK 4 ASH RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24(REN.10/831 s t EH 14-28