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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.'HAZELTON AVE. STOCKTON, GA Telephone,(209) 466-6781 PERMIT EXPIRES TYEAR FOOM DATEISSUED IGomplete In Trp ca;fte? .. Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance Na.549 for sewage of No. 1862,f or welltpump and the Rules and Regulations of the San Jaaquin- - ;; Local Health District. �WX� .. . Job Addres � — City` M Lot Size PM Owner's Name 09ZAddress Pho ContractofAAddressseNo. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES- DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL..PITS/SUMPS ! INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial " . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑'Domestic/Private ❑ Gravel Pack ❑Tracy Type of.Casing Specifications ('1 Public l_l Other ❑ Delta Depth of Grout Seal Typiof Grout" _. I I Irrigation ..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done .❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ?' Depth Filler Material IBelow 501 t; TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIR./ADDITIONA DESTRUCTION l i INo septic system permitted if public sewer is � ravailable within 200 feet.) Installation will serve: Residence Commercial_ Other. ' Number of living units: 1— Number of bedrooms y, .. C Character of soil to a depth of 3 feet: /�iU�J� ( 1—�x 'Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments. t� PKG. TREATMENT PLT.❑ n Method of Disposal Distance to nearest: Well Foundation Property Line 71gtf1-�ftif�f � FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS l I Depth Size �� Number SUMPS Distance to nearest: Well tsh2—AZ Foundation r2 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 of licensed agent's signature certifies the following: "1 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." j The applicant must call for all re airs inspections. Co fete drawing on reverse side. 7 Signa Title: ' Date: �h. FOR DEPARTMENT USE ONLY Application Accepted by Date 3 134617" Area � Pit or Grout Inspection by Data final Inspection by Date Additional Comments: y Id h— El Stk 466-6781 ❑ Lod! 3621 O 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 AMOUCK NT DUCE AMOUNT REMITTED ASH RECEIVED BY- DATE PERMIT•NO. - r ♦.EH 13-24(REV,U m 5l3=3Z EH 14-26 111 111 V f