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it h M. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 0 5 19918 t (Complete in Triplicate) ENV(ROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wFrF JSEOI[Cf s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and gulations o `tie San Joaquin Local Health District. Job Address City_ Lot Size PM Owner's Name _ Address .3 '�' Phon �__2 r Contracto4Q�y_ee Address I .. License No�37� Phonel��"v� TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION_ AGRICULTURE,W.ELL .____ _-QT-HER WELL PITS/-SUMPS_. ` q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s ['1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. LAW State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.! REPAIR/ADDITION i_I DESTRUCTION I I (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 of 3 feet: Water table depth + SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ _ _.. __' q Method of Disposal Distance to nearest: Well Foundation Property Line t:. LEACHING LINE ❑ No- ✓3t lines Length of 9 � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 1 Property Line SEEPAGE PITS I 1 Depth Sizei Number SUMPS Ll Distance to nearest: Well FoundationProperty Line .�.: —DISPOSAL-PONDS *O�- "'� _. ��.:- _..�- I hereby certify that I have prepared this application-nd'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. 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 California." The applicant u t II for all required inspections. Complete drawing on reverse side. ^� Signed X Title:. Date:��_ -�-�- FOR DEPARTMENT USE ONLY, Application Accepted by - CI �.� ''�' "' •Dat Pit or Grout Inspection by Date Final Inspection b Dat Additional Comments: k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AINOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. t EH13-24 TREY.t i n 51 � EH 14-26 ✓ Li