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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 perry it to construct and/or install the work herein described. This application is made in compliance with San Joaquin Cp my Or anerlfn. 4,9 for sewage i7r No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. G" (' ( /,�!!��Z; Job Address T'_7T_ _ City i Lot Size PM / ry�� Owner's Name j� T l p� -f(ddress L�7 `/ Phones r Contractor. &t�L'_ZLa4(ej1Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ef 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 ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I l Public 1-1 Other f_1 Delta Depth of Grout Seat Type of Grout 1 1 Irrigation ___Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done _ Well Destruction 1� Well Diameter Searing Material (top 50') Depth Filler Material {Belo $0') u TYPE OF SEPTIC WORK; NEW INSTALLATION I } REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) .Z Installation will serve: Residence— Commgrciaf Number of living units: Number bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE El No, & Length of lines ._ /' Total length/size FILTER BED ❑ Distance to nearest:Y Well Foundation L tProperty Line F3 SEEPAGE PITS I I Depth �L a _ Number_ ''��MPP5` CI 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. 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." 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant St7 7111 re rr inspections. C mprete drawing o ve se side. X=' Signed X Title: - Date: C OR 4EPARTIMENT USE ONLY Application Accepted by Date ~� Area 1 P" r rout 4nspection by Date Final Inspection br_otdG Dat-2--i�_ Additional Comments: CI Stk 466-6781 ❑ Lodi 369-3621 El 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 BY 'INF CASH RECEIVED DATE PERMIT'NO. +.EH 13-29(REV.i i H 5) EH to-zs