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APPLICATION FOR PERMIT : i ` 1 SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZEL i ON AVE., STOCKTON, CA n Telephone (209) 466-6781 2v� PERMIT EXPIRES TYEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. _ _-r, LID q /' ,, (}SCJ j. f Job Address ty PM'Cot Size I �� Address Phor)e Owner's Name �- r „ Contractor v! ��""� Address License No.t ® T� "e TYPE OF WELL/PUMP: NEW WELL ❑ = WELL REPLACEMENT D DESTRUCTION L3 -+ �"' ""PUMP INSTALLATION❑ t SYSTEM REPAIR ❑ ' ' :40TF ❑ � i h < DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES•._-�- - — -, .,DISPOSAL FLD. PROP. LINE c FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 ❑ Industrial ❑ Open Bottom ❑ Manteca yK Dia. of Well Excavation— Dia. of Well Casing r'" ' ❑"DomesticlPrivate ❑ Gravel Pack ❑ Tracyr"� `�" ; Type of Casing Specifications 1-1 Public Cl Other FI Delta h Depth of Grout Seal Type of Grout 1 1 Irrigation - --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. ; State Work Done " 3 Welt Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50db 'I t ` TYPE OF SEPTIC WORK,: NEW INSTALLATION REPAIRlADDITIO DESTRUCTION (No septic system permitted if public sewer is d , Y 8v6ilable within 200 f et.l I Installation will serve:'Residence Commercial_ Other t t i g f Number of living units: Number of bedrooms, " Character of soil to a dep"th of 3Yfeeta /Water table depth {n SEPTIC TANK ❑ Type/,Mfg—Mfg— r Capac y20�/ No. Compartments i PKG. TREATMENT PLT. 0 "k;r" Method.of Disposal - r r Distance-to nearest: Well Foundation Property L'tne, - � LEACHING LINE �No. &'Lengt of)ines t a aTotal length/size" FILTER BED ElDistance to near sf� Wel! /,06_/—Foundation�4�f Property Li er Z SEEPAGE PITS l I Depth Size j~`' X " _ lV�mber I • i E" SUMPS 0 Distance to nearest: Well i Foundation Property Line li i I DISPOSAL PONDS ❑ �' 1 I hereby certify that I have prepared this application and that the work will be done in'accordance with San`Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health Diltrict. * 'y • i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-work,forwhich this permit is Issued, I shall not I l employ any.persan 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 is-sued, I shall employ persons subject to workman's compensa Iii 'tion laws of"Califor.nia."., t The applicant; I-for all-req inspecti �Compl�eteerawing on reverse side. �J i Signed X Title: �' 4 ' t Date: 404 DEPARTMENT USE ONLY 4 Application Accepted by Date Area IJA ✓.y � a is Pit or Grout Inspection by Rate 'Final lnspection'by Date Additional Comments: .- �! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-71k ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 h: ii, fEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH r.•EH 13.24(REV.1/n sr ��"'•' �r— `� EH 14-28 ll