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JW APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 turf? 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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j �` �c�� 1 l b �� ( _;1 !^'E�� City Lot Size �JC.C� S PM Job Address II ��,�7 7 l d 4&�" fri �C Phone ^ _ 7 Owner's'Name 1t . Address•— - [. "-� / �.� "�' / I� License Noz1 � Phone Contractor Addr ss TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT D /STRCUCCTIO +A � PUMP INSTALLATION f� SYSTEM R I 1 (AJIOTHE � 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 r� X Domestic/Private Gravel Pack ❑ Tracy Type of Casing _ %t ��7� Specifications {G{4 M Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout ! . I I Irrigation __Approx. Depth t I Eastern S rface Seal Installed by _ Repair Work Done El Type of Pump a1 )01 H.P. 17L State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) W 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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,I shall employ persons subject to workman's compensa- tion laws of Californ The applicant u call for all required inspecti CompI to dr ing on re se side.%, ,- I 1 ` ,� Signed X ^ Title: �` / (�/ Date: Q FOR DEPARTMENT USE ONLY Application Accepted by __. DateL �4 Area ` Pit or Grout Inspection by Date : Final Inspection by _ Date LcSl Additional Comments:) '�- LA ❑ Stk 466-6781 ❑ Lodi Wf36211 ❑ Ma ca 823- 104 ❑ Tracy '835-6M5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. +.£H13-24(REV. ixs) / 1 6 —ILIAD EH 14-26 /// V