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I f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL I ON AVE., STOCKTON, CA 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 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. JobAddress Cityof Size PM i Owner's Name Address t . 4 . /f (-7_ /�Qj� Phone b 3 Contractor 10,ff AddressZS 1� icense No. o29O, Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ l� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '! i DISTANCE TO NEAREST: SEPTIC TANK /DO SEWER LINES DISPOSAL FLO.J00&* PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. – ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� El Industrial Ll Open Bottom X Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private t<Gravel Pack ❑ Tracy Type of Casing 'eve, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .'7 t��_ Type of Grou ❑ Irrigation -Approx. Depth ❑ Eastern Surface Seal Installed by 4 Repair Work Dane ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below-50') I TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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: 'N Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ E 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 ❑ Depth Size Number i4 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 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 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 st call for all requ' inspections. Complete drawing rave side. Signed Tit, Date: f] FOR DE RTMENT USE ONL /� Application Accepted by Date �� 7 Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`'NO. + EH W281nEV.1 85) • ©� ` �\ �r�`/ b O