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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 CC- (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 fair sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City t Size PM r j Y -Owner's Nam.7—q—ck Address � Phone Contracto AddressLicense NaVa& Phone TYPE OF WELCIPYJIyE. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION -� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION `t AGRICULTURE WELL OTHER.WELL PITS/SUMPS R °INTENDED USE ; TYPE OF WELL. PROBLEM AREA. (CONSTRUCTION SPECIFICATIONS '�,�✓ V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing r �❑ Domestic/Private—"2-Gravel-Pack,k 'I'4❑ Tracy �Type-af Casing '. ,-"-�� Specifications `- ; f Public. C, M1 ❑ Other �' ❑ Delta Depth of Grout Seal I Type of Grout I I Irrigation_ d _.Approx. Depth LI Eastern Surface Seal Installed by _ Repair Work Done. DY Type of Pump---� '. H.P. f State Work`'Done'_ Well Destruction : D' Well Diameter t.— I Sealing Material (top 50'1-- , Depth ' t Filler Material (Below 50',I TYPE OF SEPTIC WORK:-I NEW'INSTALLATION..,I.1 REPAIWADDIfi10N-1:1 * DESTRUCTION septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f Y r Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet:"'- Water table depth i -J 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 t Total length/size 4 FILTER BED' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number ; SUMPS L� Distance to nearest: Well Foundation Property Line fi 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 i 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 wotkinan's compensa- tion laws of lifornia." ° The applic nT st f all require s c ns. Complete drawing an averse side. Signed X Title: ��Z �!T iii. Date: F DEPARTMENT USE ONLY 4 ' Application Accepted by _ L Date ! Area Pit or Grout Inspection by Date Final Inspection by IAZ Date 's Additional Comments: y Z ❑ Sik 466-6781 ❑ Lodi 369-3621 LI Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Silk., CA 85201 M FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT NO. + EH 13-21(REV.tiH51 S 10 EH 14-2e 'E3 V � � 7�4