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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6* PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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,welllpump and the,Rules and Regulations of the San Joaquin Local Health District. I Job Address City Lot Size PM Owner's Name ddress Phone ..f - A..b.�- P'�'w+•^'!',�e'.w esu. -.,,,y _„wn_ro_^ -+._.....y`_ 1 Cont actor A Address__ TLO ` License No. 4phonerlL! TYPE OF WELL/PUMP: NEW WELL L1 _ELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ " SYSTEM REPAIR'=M OTHER ❑ �4 DISTANCE TO NEAREST: SEPTIC:T,ANK _ SEWER,LINES j _Ft 7DISPOSAL FLD. PROP. LINE f a FOUNDATION „ ^AGRICULTURE WELL ~OTHER WELL PITS/SUMPS INTENDED USE TYPE'OF:WELL-. 4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS G7,LIndustrial ❑ Open Bottom y ❑ Manteca..Dia of Well Excavation Dia. of Welf Casing # `❑ bomesticlPrivate ❑ Gravel Pack ❑ Tracy) Type Casing Specifications s: C7Pubiic ❑ Other ❑ Delta F Depth of Grout Seal Type of Grout ❑Irrigation ___ Approx. Depth ❑ Eastern ��Surface'Seal'Installed by i Repair Work Done ❑ Type'bUP.rn J H.P. > �`" a� State Work Donee i } Well Destruction ❑ Well Diameter "�SMaterial Itopi50'1 fi I - ealirig DepthiFiller Material {Below 501 _ ? TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is a + } ¢ J V! available within 200 feet.) lastallation will serve: Residence--�Commercial Other .w r r Number,of riving units: •s Number of bedroom§ ` ` • } .� Cha'racter of soil to a„depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity- No. CampBrtmerits ! i PKG_TREATMENTrPLT. ❑ Method of Disposal * `F t Distance to nearest: Well Foundation Property Line LEACHING LINE �YNo. & Length.of lines Total length/size I FILTER 6'ED, ' ❑ Distance to nearest: Well _ 1'k�Foundation ` Property Line Yj' SEEPAGE PITS ❑ Depth Size_ D = �`°r•`._ Number SUMPS ❑ Distance o n aresi: Well 04-4 Foundaticn., // Property Line DISPOSAL PONDS ❑ - I i- I hereby certify that I have prepared this application and that tWi ork'Will be dbne in accordance:with San Joaquin county ordinances, it ate-laWs, and - rules and regulations of the San Joaquin Local Health District.--O'. I ¢ .e � 1 - 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 'Calif 6'rnia."-Cohtractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,'l shall employ persons subject to workman's compensa- tion laws o alifornia." , s ; The applican must for ail quer ctio . Complete drawing on reverse side. p 7 _ r Signed X Title:�� I Date: F�OR�DEPARTMENT USE ONLY W T T L f k Application Accepted by ��LG+�I// i k x',. Date Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: , c� ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITN0, _ + EH 13-24(REV:rias) lata 7�° dj� EH f 4-26 n v`r .. S`