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- i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 k Local Health District. �(r-J f! �yyT.�/ L L City Lot Size PM Job Address �a—r— 00 .,��1',� Owner's Namy Address _6, � _7b `�� ZR.�•� Phone3 :SOS Contract -Address__ �C License No. TYPE OF WELLIPUM NEW WELL ❑ -;WELL REPLACEMENT ❑ DESTRUCTION ❑ T PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL'TUREFWELL OTHER WELL PITS/SUMPS INTENDED USE. c.TYRE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w 1 Q Iriffustrial y� `" ?�,H Open Botfom-" "�"❑ Manteca ��,Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C3Tracy `Type of Casing Specifications - FI Public Cl Other r n Delta Depth of Grout Seal Type of Grout_ f � � I Irrigation —Approx. Depth i I Eastern _ Surface Seal Installed by - �^ Repair Work Done ❑ Type of Pump +r";� ` �H P-,� State Work Done _ "`•' Well Destruction ❑ Well Diameter f Sealing Material ltop 50'1 k } Depth if &ler Material {Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR DD TTION DESTRUCTION I I INo.sepfic system-p_ermitted if public sewer is available within 200 feet::-I`� Installation will serve: Residence=' Commercial— Other w 1 !!! Number of living units: A_ Number of a rooms # f 4wJ W ' h 1Nater table depth' F Character of soil to a depth of 3 feet: - ttr Capacity No. Compartments - SEPTIC TANK ❑ Type/Mfg r � PKG. TREATMENT PLT, ❑ Method of Disposal Distanc e to nearest: /well Foundation Property Line LEACHING LINFAa$,Ap< No. A Length of lines "` -- To}a! length/size- FILTERBED ❑ Distance to"nearest: WeII50Foundation �'rQ ``I PropertyLne _ SEEPAGE PITS X pepih Size 1 'Nymlier SUMPS x) -1 .Distance to nearest: Well Foundation .__ Property Line .. DISPOSAL PONDS ❑* f Tin certify that'I have prepared this application and that the work rules and regulations of i -will be done in accordance with Sart Joaquin county ordinances, state laws, and �'�. '- e San_Joaquin LOG Health District. j „r_ 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, 1 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:;1 certify that in,the-performance-of the work for which this permit is issued, I shall employ persons subject to workman's compensa- a tion laws of California." The applicant m s all for all r d in ctions. Complete drawing on reverse Signed X Title: Date: --�-�- - - -� -FOR-DEPARTMENT USE-ONLY" . ._ ... Y� .,.. Date -Leto " �-sJ - Area hcation Accepted by � J s k, , �� • -- ► �� .F •� � Pit) it Grout inspection-b, Date Date ��2��Final Inspection byy ' Date ' Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO "EH 13-241REV.tiKbl EH 14-211 1