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� .. L j APPLICATION FOR PERMIT s. yI SAN JOAQUIN LOCAL HEALTH DISTRICT `-' 1601 E. HAZELTON ON AVE., STOCKTON, CA =� Telephone !2091 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 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. / /� / t , J Job Address �' * 1 /'� 1 cl / City PM F p Owner's Name u edl Ae.S Address ) A&k//X_42 U✓ Phone 1 "r Contractor's Name Q A&Cense No. Phone TYPE OF WELL/PUMP: NEW WEL ' WELL REPLACEME7NT DESTRUCTION z PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Ind ❑ Open Bottom El Manteca Dia. of Well Excavation Dia . of Well Casing !'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ��4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work done Type of Pump H.P._ State Work Done r Well Destruction 9;1"'Well Diameter n Sealing Material (top 501 Depth' Filler M'atarial'(Below 50') h TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: ;'Number of bedrooms i .Character of soil to a depth of$'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. ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line Ii DISPOSAL PONDS ❑ 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 I' 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 n in suc anner as to become subject tv an' cvr- enation laws of California." Contractor's hiring or sub-contracting signature certifies the ollowing: "I ce ify at in the perfor e o e rk f which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Calif ia." Thea li ant mu c or A require squire r plate dr ing on revs ids. Q Signed Title: Date: FOR DE RTMENT USE ONLY �7 /J Application Accepted by Date 'c` 'F Area Pit or Grout Inspection by A Date d�OJ Finalsection by Date Additional Comments: ❑ Stk 466 781 ❑ Lodi 369-3621 ❑ Manteca 823-7104- ❑ Tracy 835-6385 Applicant- Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,_CA 3520!-�` FEE` INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH GATE PERMIT Np. _ + EH 14.24(REV.10l831 �. 7�— a. � ��[X,� EH 1426 CJ Cif t