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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT G 0.0 S 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II (Complete in Triplicate) ` lication is Application is hereby mads to the San Joaquin Local Health District for a permit to construct aand the Rules and Regulations of the San Joaquin nd/or install the work herein described.This app compliance with San Joaquin County ordinance N f swage No. 1862 for'^8 p made in � Local Health District. .. �"� PMS �r.l Lot Size job'Address 5 City ✓JSP .�� vf/� �' Cs ►^ Phone W �' Address Owners Name a Phone License No. _ Contractor's Name DESTRUCTION ❑ wed TYPE OF WELL/PUMP: NEW WELL B'� WELt'REPLACEMENT;]` a., . i. �.:i,.. PUMP INSTALLATION ®� SYSTEM REPAIR ❑` OTHER'❑ P. a �� SEWER LINES .�--.DISPOSAL FLD.. - PROP. LINE , . DISTANCE TO NEAREST:.SEPTIC,TANK.� AGRICULTURE WELL OTHER WELL PITS/SUMPS L° t!`� FOUNDATION n - _Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Manteca Dia. of Well Excavation ❑ Industrial i ❑ Open Bottom 7-1 Tracy Type of Casing Specifications amesticlPrivate El Gravel Pack ❑ Delta Depth of Grout Seal Type of Grout El Public [2 Other �Approx. Depth ❑ Eastern Surface Seal Installed by ;i J ❑ Irrigation i '�. State Work Done H.P. .I i Repair Work,Done, ❑ Type of Pump Sealing Material (top 50'1.,; Well Destruction ❑ Well Diameter — t. , II Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION [YREPAIR/ADDITION ❑ DESTRUCTION C3 (No ; 1;th wirmithin feet.) if public�lsewer is I it Installation will.serve: Resid nce commercial Other i Number of living units: Number of ed oms Water table depth Character of soil to a depth of 3 feet: � ',- Capacity No. Compartments SEPTMethod of Disposal IC TANK �1 ype/Mfg ` �R PKG. TREATMENT,PLT,❑— � Property Line " Distance to nearest: Well Foundation .. Total length/size I LEACHING LINE C5 No. & L.ength of lines E Foundation Property Line FILTER.BEp ❑ Distance to nearest:f Well f A t Number_ ` E-1 epth —Size yL I SEEPAGE PITS , '' ' 4 �Property Line�s�' SUMPS ❑ Distance-td nearest:` Well Foundation—f� p rtY � ,. DISPOSAL PONDS ❑' '" '"" hereby certify that I"have prepared this-appiication and that the work will be done in accordance with San Joaquin county ordinancesjstate laws, and i I' rules and regulations of the San,J6aquin Local Health District. Home owner or licensed agent's-signature'certifias the following: "I certify that in the performance of the work for which this permit is issued, I shall not a employ any person in such trlanner as to became subject to-workman's compensation laws of California."Contractors 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 Cal'rfornia." t 1: The applicant st call for all re 'ed ns pe ions. Complete drawing on reverse side. Date: Title: Signed FOR DEPAR ENT USE ONLY y I Date Area Applicatio Accepted by f S -- -1 Final Inspection by �al•11- �— rt or Grout Inspection by T/ � Date — --- '3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 © Tracy 836385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED 63V" DATE PERMIT"i O. FEE AMOUNT DUE ANYOl1NT REMITTED ]] ,� INFO /� +En 13.24(REV.10133) i� Eli 14-26