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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) 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. �� '"" 7f�je��S� +� S� �N sry/� D� F�Dnr Nr, acs rPM Job Acity A57 kW_ Lot Size z Owner's Pane,-,1 ��3 Y, 1D Address- �r�4�4 /1'el - Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Q PUMP INSTALLATION 5." ' SYSTEM'REPAIR-1] --1 OTH5R ❑ DISTANCE TO NEAREST: SEPTIC TANK IM y' SEVITER LINES DISPOSAL FLD.1,75-f PROP. LINE 2x/!f, D FOUNDATION AGRICULTURE IMI=LLC "� - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial t D.-.Open Bottom—EI-Manteca—,—Dia.-cif WeII-Excavra on'" Dia. of Well Casing Domestic/Private ?Gravel Pack -❑"Trac ` T Specifications / Y- - yperof Casing ❑ Ali, � ❑'Other �; ❑ Delta Depth of Grout Seal �r'C� : `�! ; Type of Grout d Irrig'ation' c-R-0-A pprox. Depth ❑ Eastern Suri Seal Installed by Repair Work Done El Tape of Pump' _ H.P._ State Work Done Well Destruction © WeII Diameters . Sealing Material {top 501 ice ) i Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0-(No septic system permitted if public sewer is ---- available within 200 feet.) Installation will sere: Residence_ Commercial_ Other n I Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: - " �NVater table depth SEPTIC TANK El 'Type/Mfg", ' !r,; Capacity i No.' Compartments PKG. TREATMENT PLT. ❑ ! "` Y'� Mets od of Disposal Distance. 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 Depth y . Size Number SUMPS ❑ Distance ta'riea`rest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this appli6ation 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. ' "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the wo � ` for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." , _ The applicant mu c requir ctions. Complete drawing on side. Signed X� _ Title: Date: r EPARTMENT USE ONLY I j{ Application Accepted by s _ __ u w Date Area _ Pit or Grout Inspection by y Date .57- 7-47 Final Inspection by `� Date Additional Comments: ""`� El Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ` n CASH p� + EH 1 111 3-2/1 REV.F/a 51 1 EH 1428