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k APPLICATION FOR PERMIT �{ . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (269) 466-6781 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I� City t Size PM Owner's Name t� dress =A Phone �' ' A�X /� Contractor ss License No. Phanee TYPE OF WEL . : ` "NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP'INSTAL-LATION;171—, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC—TANK------ SEWER-LINES DISPOSAL FLO. PROP. LINE FOUNDATI'OKI` '"'°""� AGRIEULTURE 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 h Type of Casing Specifications 171 Public ❑ Other F-1 Delta Depth of Grout Seal Type of Grout 1 Irrigation Approx, Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter S ing Material (top.50') i Depth Filler Material l8elow 50'I — TYPE OF SEPTIC WORK: NEW INSTALLATION,I REPAIR/ADDITION I 1 DESTRUCTION l 1 INo septic system permitted if public sewer is available wit I 200 feet. .. Installation will serve: Residence Commercial Other- G Number of living units: Number of bedrooms j Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ILIANo. Compartments PKG. TREATMENT PLT. ❑ n Method`of Disposal Distance to nearest: Welle,,e5g;/dion fJ Property Line LEACHING LINE ❑ No. & Length of lines _ 4T-otaHength'/size-"•" v FILTER BED ❑ Distance to pearest: WeilIf a on Property Line tef SEEPAGE PITS f I Depth Size Number SU S ❑ Distance to nearest: Well dation Prope ine I e DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be ane 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 shalt not laws of California."Contractor's hiring or sub-contfactin signature employ any person in such manner as to become subject to workman's compensation a s g 9 9 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 applica •m for a uire inspe ns Complete d ing on rev se Si e. f Signed rtle; Date: a✓ . FOR DEPAR ENT USE ONLY J Application Accepted by4. & Date ��Area/ ` p Pit or Grout Inspection by Date Final 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 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24 iREV.1/x51 r EH 14-28 70