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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZETON 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 permit to construct and/or install the work herein described. This application is made in compliance with an JoagWa Co ty Ord' nce N 9 fo sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 3 �-fdQA"� c 1^k AA,a.a�� * �f 1 �1 v (X1a � Lot Size yc PM Owner's Nam Address Phone Contractor', . _ Address C-' erase No.32 77+ Phone, dw TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; t 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 SpecificationsN f'1 Public ❑ Other Cl Delta Depth of Grout Seal y Type of Grout + I 1 Irrigation _..Approx. Depth I I 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 f=iller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 6ESTRUCTION•11 INo septic system permitted if public sewer is V, ; available within 200 feet.) Installation will serve: Residence _L Commercial _ ther Number of living units: —/— Number of bedroo' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ffl-Type'/MfgCapacity--_±n—No. Compartments PKG. TREATMENT PLT. Cl ;Method of, Disposal Distance to nearest: Well Foundation Property Line-" - LEACHING LINE Nos;& Length of lines ` Total length/size X FILTER BED ❑ Distance to nearest: Well f Foundation Property Line.— i V f SEEPAGE PITS. I I DepthT: Size Number y.a SUMPS L7 Distance"to nearest: Wel! Foundation/' Property Line DISPOSAL PONDS ❑, r 7 I hereby certify that I have,repared this application and that the work will be done i accordance with San.Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensed agents 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." The applicant must coilr II required ins do .Complete drawing on reversetd Signed 4Title: �`// V Date: FOR DEPARTMENT USE ONLY—_. Application Accepted by'?Date Area W Pit or Grout Inspection by Date Final Inspection by 0 Additional 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 ♦. EH 13-24 (Rev, t / H 5) EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT .NO. rn--y�ek- I �-- i ab3 V