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APPLICATION FOR PERMIT rM SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 486-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED - i S' ciJ•..� �� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ihstall the work herein described. This application is made in compliance witjb_S)n oaquin�Ord'npnFe�N01 548 fouewage or No. 1862 fwell/pump and the Rules and Regulations of the San Joaquin Local Health Distric . / r7Z YFff � Job Address / /Q City lrQG Lot Siie � •!yamI •? PM Owner's Nam S� Address Phone 1 . I� eyKaf Contractor�yL� / Address S CO/ icense No. 8 a Phone S-� 3 TYPE OF WELL/PUMP: ��. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack x1facy Type of Casing Specifications 4� M Public her H Delta Depth of Grout Seal Type of Grout I I irrigation �.Approx. Depth l I Eastern Surface Seal Installed by "1 ' Repair Work Done 11Typ'of Pump y H.P. State Work Done Well Destruction )24 Well Diameter �O Sealing Material (top 50') ^/w r Depth /�' Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is it available within 200 feet.) Installation will serve: Residence— Commercial_ Other C Number of living units: I� Number of bedrooms dy Character of soil to a depth of 3 feet: Water table depth ` 'SEPTIC TANK' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El �� Method of Disposal Distance to nearest: Well Foundation Property Line µ LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number 1l ¢ SUMPS Ll 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 Sari 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. r 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." I� The applicant m st call far re uired ' ctions. Complete drawing on verse�sie. Signed Title: 4 Date: R DEPARTMENT USE ONLY g Application Accepted by Date Z3 �U�Area 0 Pit or Grout Inspection by Date Final Inspection by Date T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3611 16 a 823-71 ❑ Tracy 83AM5 Applicant Return all copies to:.EnviW, ental Health Per ' Services 1601 E. yazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0, + EH 13-24(REV.f/95) � EH 14.28 3s o��i - - I� 111