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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT = 1601 E. HAZEL T ON AVE., STOCKTON,"CA yU� Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (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 is k 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. i Job Address City Lot Size PM Owner's Name I" r Address Phone Contractor,—/—&M el- a,#2—S?`_Address k License No�64 SaQ 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 AGRICOLTURE,"V4/'ELL,:- OTHER WELL PITS/SUMPS ------------------------------------------- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑_Manteca w._ T Dia. of Well Excavation. + _" - - Dia. of Well Casing II ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing ii Public Specifications f1 Other n Delta ` :Depth-of Gfo`ufSeal - T I Irrigation _._Approx, Depth I i Eastern i Ype of Grout t Surface Seal.Installed by I , Repair Work Done ❑ Type of Pump H.P. � —.L---State Work Done _ i Well Destruction ID Well Diameter Sealing Material (top 50') 1 Depth Filler Material (Below 501) -�-� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Other available within 200 feet.I Number of living units: Number of bedrooms Character of soil-to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depthCa acit P Y No. Compartments PKG, TREATMENT PLT. C Method of Disposal Distance to nearest: . Well Foundation Property Line - i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS t L1 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 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 followi "1 a y 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 Calif n The applicant m t 11 required inspections. Complete drawing on reverse side, Signed X Title: _ 4A—M)&r _ pate: f FOR DEPARTMENT USE ONLY l Application Accepted by p Date �f �� Area f Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: 14Z U C1Stk 466 6781 Lodi 3fig-3621 ❑ Manteca 11234T04 ❑ Tracy 83 6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM NT MITTED CK INFO CASE! RECEIVED BY DATE PERMIT'NO. ♦ EH 13-24 tRE'V.r i H 51 - EH 14-28 F