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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED 7-16(Complete in Triplicate) V�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theCuaaq.Eeau herein described. This applicati i) i made in compliance with San Joaquin County Ordinance N .19for.sewage or No. 1862 for well/pump and the lationsof the San Joaquin Local Health District. Job Address /L/2/,J CityLot Size_ PM by k Gf Owner's Name Address Phone / - "t"Contfactory _ License No;� � Phone ,- § F ' ! TYPE OF WELL/PUMP: NEW W LL WELL REPLACEMENT El DESTRUCTION ❑ t .f PUMP INSTALLATION ❑ SYSTEM.REPAIR El OTHER ❑ 4 ' DISTANCE TO NEAREST: SEPTIC TANK,(' ..SEWER LINES DISPOSAL'FLD. _ PROP. LINE FOUNDATION AGRICULTUR eL OTHER WELL _ PITS/SUMPS i INTENDED'US,E. TYPE OF,WELL�PROBL A CONSTRUCTION SPECIFICATIONS G 3 y ❑ Industrial "' ❑ Open Bottom ❑ Ma a - Dia..of•.,WeILExcavation -- -- _ .IDia of Well Casing ❑ Domestic/Private Z,aracy Type of Casing Specifications f l Public F..1 Delta, Depth of Grout Seal Type of Grout I I Irrigation l I Eastern '�–,Surface Seal Installed byRepair Work Done ❑ H�'. >- State Work Done1 Well Destruction` ❑ Sea gMaterial (top 50')Filler terial`(Below 501 — { TYPE OF SEPTIC WORK: :NEW INSTALLA.11ON Ia REPAIR/ADDITIO•N t DESTRUCTION I I (No septic system permitted if public sewer is �- available within 200 feet.) d Installation will serve Residence* Commercial Other Number of living units Number of bedrooms-9i_`�.- 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ! ❑ TVpe/Mfg or Capacit Cf No. Compartments r. PKG. TREATMENT PLT. ❑ a i Method o Disposal e Distance to nearest: Well Foundation--= Property Line t s LEACHING LINE. ❑ No. & Len gth lines To I length/size FILTER BED ❑.q,,,_D.stance,to nearest:, Well *undation / Property Lined- j SEEPAGE PITS .. k 1.1 t Depth i t NAIMhAr SUMPS,,"' ,1 ; Ll Distance to ne st: Well Pbundation Property Line DISPOSAL PONDS ❑` i 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 California." y The applicamust call f required inspections. Complete drawing on reverse side. Signed X 4 Title: _ / _ Date: FO AFITMENT USE ONLY F Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by / i Date 4 l Additional Comments: t• i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 's u Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r � j I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY _ DATE _ PER_MIT'NO. --�- _INFO.. _.__.._._.CASH_ _ +-EH13-24(REV.tin 5) EH 14-26