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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAk ; . N P Tele hone (209) 466-6781 "r1�t�il � 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 J'�pquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f c Job Address City If of Size PM Owner's Name [' Address _ r i�. � _ Phone r� Contractor Address �- License No. Z GW-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EDOpen Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth A l Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence X_ Commercial ____ Other 0 Number of living units: _/-- Number of bedrooms 3'""� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity or No. Compartments -� PKG, TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation .r C> Property Line . r r'. LEACHING LINE P��No. & Length of lines Tol length/size r FILTER BED 171 Distance to nearest: Well 'Foundation Property Line r i SEEPAGE PITS � epth Size—3-3 - / Number -�� SUMPS [1 Distance to nearest: Well�L Q_rFoundation. 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, art 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(t 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: "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 must for all req 'e ins tions. Complete drawing on reverse side. Signed Title: fn//�+�1 - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `;��a Area or Grout Inspection by .00 '12� Data inal Inspection'by T�c-� Date 4111 tttAdditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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] CK H RECEIVED BY DATE PERMIT'NO. r . y INFO f j +.EH13-24tREV.I/H5) �' �— EH 14-28 7T 7