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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZE'TON 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 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address a City ' t La o#Size / PM C � r , Owner's Name Address Phone Contractor Addressicense No: / Phone16D �I TYPE OF WELL/PUMP: NEW WELL 1-1WELL LACEMENT 1:1DESTRUCTION ❑ - l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r FOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL _-.._ _,-- OTHER WELL__t_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r i Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by [ '�A i -% Repair Work Done ❑ Type of Pump H.P, I State Work Done JIT I/, Well Destruction ❑ Well Diameter Sealing Material (top 50') ; I Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: N W INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Available within 200 feet.) Installation will serve: R dente v Commercial _ Other Number of living urns: Number of bed s q Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 9 Type/Mfg 1� � Capacity!L-11-00 No. Compartments PKG. TREATMENT PLT: ❑ - �� Method of Disposal t Distance to nearest: Well D E• Foundation `"�"!O I Property Line LEACHING LINE JW No. & Length of lines 4 s� `' Total length/size FILTER BED ❑ Distance to nearest: Well t � _ Foundation Property Line SEEPAGE PITS ILI DepthNumber SUMPS ❑ Distance to nearest:'' Well—Foundation,..i_ 11'_ -_Property Line DISPOSAL PONDS 13. hereby certify that I have p(epared-thi's 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 Ith District. 1 '•'',/�, �.F�A��A. A I Home owner or licensed-agent's-signature cert a the#ollowing: "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 bee a ubject to workman's"compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:'l,ce 'fy tha 'a th rfor a e of the work fol which this permit is'issued, 1 shall employ persons subject to workman's compensa- tion laws of Calif fxga�l i The applican .t,fust cal o re it i mplete drawing on reverse side. Signed Title: __I —? Date: FOR DEPARTMENT USE ONLY Application Accepted by} Date � $s Area —Pit or Grout-Ihspection by DateFinal Inspection by�'"� �"" —`Date�� S Additional Comments: Y\ ❑ Stk 466-6781 ❑ Lodi 369-3621 Manfeca_823=7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental 41th Pe mit/Services 1601 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED_ K RECEIVED BY DATE PERMIT"NO. +EH1324(REV.1/85) -T S �� y� �a-?�-r!s EH 14-25 i J