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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I. 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Applicaton is hereby t and/or all the work herein described, This cation is made in Icompl compliance with made SanoJoaqu nthe SanCoungty Ordinance No. 549 for sewage or Joauin Local Health District for a permit 1862 for cwell/pump atnd the Rules and Regulations of he San l Joaquin Local Health District. 01 Job Address City / Lot Size. Y L?'LJ!CR+3 4• z PM Owner's Name Address.16 Phone �J�e I Contractor Address License No. Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT&r DESTRUCTION ❑ .PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Dia. of Well Casing Dia. of Well Excavation 9 l ❑ Domestic/Private C1Gravel Pack F1Tracy Type of Casing Specifications t i i"1 Public F] Other n Delta Depth of Grout Seal Type of Grout - A. �J�Irrigation --.,Approx.-Depth t-)-Eastern. Surface SeaLlnstalled by 'Repair Work Done ❑ Type of Pump H•P State Work Done I Well Destruction ❑ Well Diameter Sealia® trial Uop.50'1 f Depth F'I terial I Below 501 F TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t ] DESTRUCTION I 1 INo septic system permitted if public sewer is = available within 200 feet.) ! Installation will serve: Residence— Commercial_ Other Number of living units: . Number of bedrooms P V' Character of soil to a depth of 3 feet: Water table depth r 1 r 1 i lJ" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r n PKG. TREATMENT PLT. ❑ Method of Disposal V Distance to nearest: Well Foundation Property Line WP LEACHING LINE ❑ No. & Length of lines Total length/size rn FILTER BED ❑ Distance to,nearest: Well Foundation Property Line �- SEEPAGE PITS f i Depth Size Number { SUMPS L71 Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ ' I hereby certify that ! 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 Dj%trict.r- - .— 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 subcontracting 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 -i-- � tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side.'. # 4_1aw _ ` Signed X Title: f Date: f r - t R DEPARTMENT USE ONLY 9 Application Accepted by Date r`� Area f � Pit or Grout Inspection by Data Fina! Inspection by i )rv, —� - Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 ¢ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 t FEE MOUNT DUE AMOUNT REMITTED CCK# RECEIVED 8Y DATE M_4_�31 INFO 1/ 1:3+.EH13-24{REV.1/n5) (°� Q� l 1( S ^ �—�D EH 14-28 L� l f '�