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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'i + � 1601 E. HAZELTON AVE., STOCKTON, CA L4 3Ul• Telephone (209) 466-6781 I 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. 1662 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. n Job Address City '/�'�°a� Lot Size PM a Lk f 'llh1L Owner's Name f' .� , , Address Phone Contractor eAA S_? _j '"`"� — Address License No. W57?-_L6 3 Phone 'l-13�� TYPE OF WELL/PUMP: NEW WELLX75 WELL REPLACEMENT 0 DESTRUCTION L7 PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER�Q A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial Open Bottom Manteca Dia. of Well Excavation & I Dia. of Well Casing Z 'Domestic/Private V_Gravel Pack ❑ Tracy Type of Casing 4A Specifications �^,, M Public ❑ Other C-1 Delta Depth of Grout Seal + Type of Grout t.N-,/&4 _ I Irrigation _Approx. Depth I I Eastern Surface Sual Installed by >r't�tt+r Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction E] Well Well Diameter _ Sealing Material (top 50'1 Depth ls�Zo Filler Material Ieelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is Q 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 I I Depth Size _ Number SUMPS CI Distance to nearest: Well Foundation Property Line 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 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 taws of California." The applican c red inspections. Complete drawing o er de. Signed X TitlL. e: Date: L lk— FO DEPARTMENT USE ONLY Application Accepted by Date r oA rea Pit or Grout Inspection by DateFinal Inspection by Date/ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH1 3-24(REV.1/a5) {� f %� (`��' EH 14-29 9 4 'l r yGa �� 6