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I t N, d. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED F (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 a or g o. made in compliance with San Joaquin County Ordinance No. 549 for sews N 1862 for Local Health District. well/pump and the Rules and Regulations of the San Joaquin Job Address � / ) Iy City Lot Size I "� PM Owner's NameAddress Phone +- ,y�, Contractor Address l- � License No. Phone 1 , TYPE OF WELL/PUMP: NEW WELL ❑ ` WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ "-`SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK y OTHEfi D DISTANCE " t x SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED , TYPE OF'WELL _OBLEM AREA CONSTRUCTION SPECIFICATIONS N.Cl Industrial ❑ Manteca Dla. of Well Excavation I �omestic/Private ❑ vel Pack Ll Trac Dia. of Well Casing " Y Type of Casing ❑ Public 0 Other c ❑ � Specificatioris I F Depth of Grout Seal` Type of Grout ❑ Irrigation �pprox.,De Depth ❑ Eastern p Surface Seal'Installed by Repair W Done ❑ ',Type of Pump H p f F -..� State Work Done ; v We estruction ❑ Well Diameter Sealing Material (top 50') T ¢ Depth Filler Material (Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is c Installation will serve: Residence v Commercial available within 200 feet.) Other Number of living units: Number of bedrooms fff iii F Character of soil to a dap of 3 feet: .,..� # SEPTIC TANK Water table depth------------------- , ❑ Type/Mfg opacity �� No. Compartments PKG. TREATMENT PLT. ❑ Ctf�ff p t i Method of Disposal i 1 Distance to nearest: Well Foundation PropentVIine" LEACHING-LINE ❑ No. & Length of lines_, ,��E9.�.f3 dotal length/size I FILTER BED ❑ Distance to nearest: Well �"u'St Foundation Property Line SEEPAGE PITS ❑ Depth I Sizeof E Number �. SUMPS A. Distance to nearest: Well Foundation ' i f DISPOSAL PONDS ❑ ' Property Line 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: P to an '"I certify that in the performance.of the work for which this permit is issued, I shall not am P Y y person in such manner as to become subject to workman's compensation laws of CaliGnia."-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 shallemploy.persons subject to workman's compensa- tion laws of California." ,t,..� The applicant must call for all required inspections. Complete drawing on reverse side. r Signed X__ - /�j � Title:L�t'rC11-.r. Ft i..i Q r � Date: CJ FOR DEPARTMENT`USE ONLY Application Accepted by f ,. pDate . Area Pit or Grout Inspection by Date`11 gI?t, Final Inspection by Date Additional Comments: ❑ Stk 466-6781_.-....T..--Q..Lodi--369-3621_- �p-Manteca-823-7104- Tracy-835:6385— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.FHazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO (� CASH RECEIVED 8Y UA`f' LPERMIT'NO. a EH 13-24 lr'tEY. i H 51EH 14-28 1:V j `1 I