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a� "" .. APPLICATION FOR PERMIT JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 " PERMIT EXPIRES 1 YEAR 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 d made in compliance with San Joaquin County Ordinance No.549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � City Lot Size GAG X PM Owner's Name ��v Address Phone 17— Contractor + � � Address fif /°,2 License No, a Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ', PUMP INSTALLATIQ / SYSTEM REPAIR ❑ OTHER 1-1p DISTANCE TO NEAREST: SEPTIC TANK !�� i SEWER LINES DISPOSAL FLD. ---- PROP. LINE _FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE T E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �+f ❑ Industrial ❑OpeR--Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t 1 ❑ Tracy 9Amomestic/Private '_Gravel Pack Type of Casin pecifications 414 l-1 Public ❑ Other Ml n Delta Depth of Grout Sea! Type of Grout I I Irrigation /0� pprox.'Depth I i Eastern Suria//c��Seal Ilnyst�ailed by - ' L/ ir77Y State Work Done, Repair Work Done ❑ Type of Pump=_ H.P. �.� Well Destruction ❑ Well Diameter Sealing Material (top 501 111 Depth Filler Material (Below 501 T PE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is f available within 200 feet.) - Installation will serve: Residence*# Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments h 4 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propdrty,Line k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS 11 Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -t 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 far which this permit is issued, I shat!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." The applicant must II quire '� tions. Complete drawing on rev averse 'da. Signed X /% �,Title: 0� Date: FOR DEPARTMENT USE ONLY Application Accepted by r �� Date 45—/ Area Pit or Grout Inspection by Date Final Inspection by� ! Additional Com ts: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 8#7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 9520 B C4y I &—oro (OS`b ss' tfn FEE AMOUNT DUE f AMOUNT REMITTED CASH RECEIVED BY DAT RMIT'NO. INFO 13-241REV.tin_51 - Q .y •�'�� r'^� -'r q „ EH 14-P8�