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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE.;-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM"DATE ISSUED v (Complete_in Triplicate) s 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 No.549 for sewage or No. 1862 for well/pump-and the Rules.and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District: City /. �- "L etSize PM Job Address T Phone Owner's Name Address �01 9c 7 r .7 Q License No. Phone i Contractor / Address �/ f TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP 1iJSTALLATION.❑*` J. SYSTEM flE.11 PAIROTHER "❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA'4 CONSTRUCTION-SPECIFICATIONS; Dia. of Well Casing, . '. ❑ Industrial ❑ Open Bottom '❑ Manteca- Dia. of(Nell Excavation � .. y "• �--�-- ` ' Specifications )Q_Domestic/Private?v, �O-Gravel Pack ` —D Tracy , '' Type of Casing r t ❑ Delta Depth of Grout Seal Type of Grout a El Public ❑ Other ` ---Approx. De th ❑ Eastern 5urfa Seal Installed by ❑ Irrigation —SPP p H p State WorkOone Repair Work Done j Type of Pump — ?--- 'Well Destruction ❑ Well Diameter Sealing Material (top 5011 s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION. DESTRUCTION I ION ❑"avail blelwithin 20rn 0 feet.) if public sewer is 41 Number Installation will serve: Residence Commercial Other kNumber of living units: Number of bedrooms - Water table depth + Character of soil to a depth of 3 feet: r ` F] _- 'Capacity - w No. Compartments. , SEPTIC TANK Type/Mfg Method of-Disposal_ PKG. TREATMENT PLT. ❑ !. i f 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 t Number SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 4 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., ertify 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: "I c 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: 111 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 applic must all for all require pection Comp a drawing on reverse side. Date: Signed X Title: a _ FOR DEPARTMENT USE ONLY �y ap r a m) Application Accepted by / [ "�" "`�! Date U Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: E3 Stk 466-6781 EJ Lodi 369-3621 El 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 g, FEE `AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY HATE PERMIT N0. INFO + EH13.241REV.1/85 EH 14-28