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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (209) 466-67$1 ' 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 " or No. 1862 for well/ and Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. -1"' JabAddress a° City Lot-Size PM � /t.11t� _ I re Phone z Owner's Name _...:,qll Address Contractor S Address License No, 2 6 Phone TYPE OF WELL/PUMP: AEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK =SEWER LINES DISPOSAL FLD./,5D PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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_ c— Specifications [IPublic ❑ Other LlDelta n Depth of Grout Seal 00 Type of Grou ❑ Irrigation —�pprox. Depth ❑ Eastern Surface Seal Installed by (CA Repair Work Done L1Type of Pump H.P. State Work Done s Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 501 I h TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is v—{ available within 200 feet.) Installation will-serve:,- Residence—+Commercial 'Ot r – + Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Cape it No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: ell Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size k Number SUMPS C1 Distance to nearest: Well r Foundation Property Line €. DISPOSAL PONDS ..._. ❑ r 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. 4 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 4 of California."Contractor's hiring subcontracting signature employ any person in such manner as to become subject to workman's compensation laws loy p ersons subject to workman's compensa 4 certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ p tion laws of CalifHe." The appli ant m t call for all require + pections. Complete drawing on revers side. / I Titie j Date: 49 Signed OR DEPARTMENT USE ONLY ' O Date Area 6 Application Accepted by f Date Final Inspection by Dat Pit or Grout Inspection by Additional Comments: l " ❑ 5tk 466 6781 L anteca 823-7'104 racy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 t. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ! + EH 13.24{REV.1/a 5] ✓ 70 ov '33 EN 14-28 .. ttL/// - 4 -