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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �1 1601 E. HAZE T ON AVE., STOCKTON, CA p GEI Telephone (209) 466-6781 R PERMIT EXPIRES 1YEAR FROM DATE ISSUED `41 13 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein $Ldvr'Is made in compliance with San,Joaquin•County Ordinance:-No 549'1or sewage or No. 1862 for welllpump and the Rules and R I ti taV � n oaquin Local Health'Distract FfK� "r5i a a r ``ta ; 'a t `''' # t �ev„y ..5-7zFJ'�'' s "Ir.. _.'V'X-� Joh Address C1 '°! 11 � ' `tY — City Lot Size PM Owner's Name �+ � �Gxdress �t• *, Phone Contractor�;Lf ressa35z5 l tf l & ense No.G29'L1�1 Phone TYPE OF WELL/PUMP: NEW WELLN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A d SEWER LINES DISPOSAL FLD.W01 / PROP. LINE-'7 FOUNDATION AGRICULTURE WELL OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing. XDomestic/Private Gravel Pack X Tracy Type of Casing P�G Specifications t� F1 Public C1 Other ❑ Delta. Depth of Grout Seal Type Grout�l I'I irrigation __Approx. Depth I I Eastern Surface Seal installed by.. .[t.l_�L� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 501 (In^ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIWADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 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 l I Depth Size Number SUMPS ❑ "Distance to nearest: Well Foundation Property Line "DISPOSAL PONDS D I hereby certify that t 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 DiMrict. 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." The applicant m t call for all required 'nspections. Com late drawing on reverse si a. '�7 Signed X Title: Dater- ' 01R r�OA MENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments; C] Stk 466 6781r`._i;<- ❑ 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 FEE INFO /t AMOUNT DUE AMOUNT REMITTED CCASH K It RECEIVED BY DATE '.FIEERMIT'NO. +.EH 13-24IREV.aiHsf / �//' �' ,� EH 14-Ze 6 ��VJJ