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APPLICATION FOR PERMIT` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. '0,00(/ Job Address C SC/�� L�P_�OT�% City Lot Size PM Owner's Name Address 6 X 13 1 Phone p Contractor's Name APM 0 P(A'&Uleense No. Phone R --/2-C239<,/ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ :.c PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK 1 �O r SEWER LINES // N- DISPOSAL FLD.1/0:;� PROP. LINE + FOUNDATION D' AGRICULTURE WELL AxQP OTHER WELL-bfteQ—_ PITS/SUMPS f rn INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &S/ i Domestic/ Private ;I Gravel Pack ❑ Tracy Type of Casing. '12 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern ,,Surface Seal Installed by Repair Work Done ❑ , Type of Pump H. P. —State Work Done Well Destruction 71' 1Nell Diameter Sealing Material {top 5011 'Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence _ Commercial _ Other Number of living units:, Number of bedrooms Character of soil to a depth df,3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well " Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nea�iest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size 4 ' Number + SUMPS ❑ 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 San Joaquin Local Health District. , f 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 California." Contractors 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 Californi The applicant u call for all required inspectComplete drawing on r'verse side. SignedTitle: �{. Date: r OF FOR DEPA ENT USE,ONLY Application Accepted byDate Area Pit or Grout Inspection by LL„t►,. ;?,te Final Inspection by _a..!��ate� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7144 ❑ Tracy 835-6385." 1 Applicant - Return all copies to: Environmental WealtA Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 (REV. 10183) H 14-28 INFO AMOUNT DUE AMOUNT REMITTED CA 4 J RECEIVED BY DATE PERMIT"NO. �`�' :.c $ 4 -11 s Li I + 6 �s • e, `7 �-t3 7 g rnV t` O .1