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APPLICATION FOR PERMIT d �,_. SAN JOAQUIN LOCAL HEALTH DISTRICT C } 1601 E. HAZE T ON AVE. STOCKTON GA ,I Telephone 1209) 466-6781 f PERMIT EXPIRES 1;YEAR FROM DATE ISSUED V (Complete in,Triplicate) r. 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 I 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 —MI `=1: ``,, + ( City G Lot Size t'sU ply v' Owner's Name I'1 Address l 5. ��;s7c.k'0�K Phone Wan Contractor liC�.�}y Q 1 h bQW_Le Hs�ddress License Mo. Phone 4-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEARES TIC TANK SEWER LINES DISPOSAL-FD'r PROP. LINE FOU NDA AG R I CU LTU R E.W:EL L a OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBL EICONSTRUCTION SPECIFICATIONS C] Industrial EJ Open Bottom 11_"Zr- — Dia-_o { cavation Dia. of Well Casing } ❑ Domestic/Private 0 Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of GrouFteal 5 A `Typef'af Grout i ❑ Irrigation < �Ty. ox. Depth ❑ Eastern Surface.-Seal Installed by... ' Repair Work Do ump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 54.1 I _ _ Depth t Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION)q (No septic system permitted if public sewer is F ` .available within 200 fee(.) Installation will serve: Residence= 'Commercial t Other Number of living units: Number of bedrooms wr Character of soil to a depth of 3 feet: j Water table depth'' I: SEPTIC'TANK L_ -Water i_Type/Mfg ? Capacity': No. Compartments PKG. TREATMENT PLT. ❑ '04" lKi Method of Disposal Distance to nearest: Well Foundation Property Line t 1 � t LEACHING LINE ❑ No. & Length of lines I Total lengthlsize ,r FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ❑ Depth f'I Size_ Number SUMPS ,.. ,, ,,n :Distance' to nearest: Well- _- - - -Foundation-- MProperty Line- DISPOSAL PONDS,. ❑ I ` I hereby certify thaf,I have prepared thiss 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, 1 shall not i employ any person in such manner as to become 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 comperisa- tion laws of California." .the The applicant must call for all required inspections. Complete drawing on reverse side. � Signed X_ ' ��{�-�-p—�J, Title: Date: 6 -(F// .= r € FOR :DEPARTMENT USE ONLY �. Application Accepted by ate Pit or Grout Inspection by Date Final Inspection by o bio S e Additional Comments. CO ❑ Stk 466-6781. ❑ Lodi 369421 ❑ M teca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave., P.O..Box 2049, Stk., CA 95201 Icai�1 O'i.�Gr FEE INFO AMOUNT DUE,t AMOUNT/R�EM(7TEp ` CK H IV RECEIVED'BY DA/TE P�EjRMIT N + EH 14-24'REV.i-Iasi 3 EH 14-28 cJv� J /ice' D