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SGP 211984 APPLICATION FOR PERMIT SAN JOAQ.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SAN j0p,QUIN LWIL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �IFAL-CH �� R��•� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. Job Address City City of Size PM Owner's Name Address) Phone Contractor's Name License No. C1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I)t OTHER I( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS SI.I[�►I.7�1�1��.9� O Industrial )t Domestic/ Private ❑ Public Cl Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other ❑ Delta Depth of Grout Seal --Approx. Depth ❑ Eastern Surface Seal Installed by Type of Pump H. P. l State Work Done Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. 0 Dia. of Well Casing Specifications Type of Grout r c system permitted if public sewer is within 200 feet.) Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation Method of Disposal Property Line ON W I" r c3�7 C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 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 laws of California." The applicant st cat] fora uired inspections. Complete drawing on reverse side. Signed i Title: ��'�-a / Date: FOR DEPARTMENT USE ONLY Application Accepted by _ �-�Cti\ � DateQ 2� —��(� Area Pit or Grout Inspection by Date Final Inspection by O&D�t\tkk "...,aA.. DateZa-JfJ `1 Additional Comments: ❑ Stk 4664781 ❑ 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 + EH 13-24 IREV. 10183 EH 14-20 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED 9Y DATE PERMIT"N0.1 L�S "T 3354-4�q