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x APPLICATION FOR PERMITS 4/0 �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) x 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./1 177 r AWAJob Address City Lot Size PM Owner's Name Address... � n Contractor dd�ress License No: P�fione TYPE OF W L/PUMP: NEW WELL &0 -WELU REPLACEMENT O-� DESTRUCTION ❑ PUMP INSTALLATION l/ SYSTEM REPAIR ❑ OTHER ❑ ��I$TANCE,T NEAREST-SEPTIC-TANK - — -SEWER+-INES---=----••-- 0ISPOSAL.FLU. _PR Pp,114 - FOUWATION II�f AGRICULTURE WELL ZS OTHER WELL rr PtTS/SUMPS .— INTENDED USS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ ustrial }i Open-Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing U Lf Domestic/Privafe ID 'Gravel Pack ❑ Tracy Type of Casing �,�. Specifications (� ! (1 Public i f i Other., (1 Delta r---- "Depth�of'Grout'�Seal _r Type of Grout /� - F ' 11.1 Irrigation j --Approx. Depth l I Eastern Surface Seal lnstalledp_y c _ Repair Work Done' ❑ Type of Pump �w� IH.P. L `tom;! It N State Work Done Well Destruction ❑ Well Diameter - Sealing Material ftop 50'1 Depth E_ �+ �Fitler Material-iBelow-50'1 � v,� TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION i.l DESTRUCTION [ I (No septic system permitted if public sewer is i "J available within 200 feet.) e Installation will serve: Residence_ 'Com cial s Other 1 Number of livinj units: Number of bedrooms--l: sCharacter of soil to a depth of 3 feet: Water table depth �S SEPTIC-TANK_3 I ❑ Type/Mfg. ( Capacity- - No. Compartments PICGi . TREATMENT PLT. ❑ Method'of•Disposal 1 Distance to nearest: Well Foundation Property-Line l t LEACHING LINE 1 ❑ No. & Length of lines Total length/size I 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 . ❑ 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 Di§trict. f 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, 1 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 I 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." i The applicant st for all requi d ins tions. Complete rawing on reverse st 1 Signed X Title: /lt"1 Date: OR DEPARTMENT USE ONLY - Application Accepted by Date !'LOQ E `Area` Ir Pit out Inspection b ate Final Inspection by -W��!//I�'rtc�t�bate �� I r -� Additional Comments: ❑ Stk 466-6781 0 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY A7 PERMIT-NO. +,EH 13-24(REV.1/8 5) G p`]� EH 14-28 �. J -� 0 ri —