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. v .: p -- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON 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 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. q City [� Lot Size /►t �M Job Address _Z it 4`� ra fig v/.AQds$ 7 Phone �J Owner's Name Phone Coiltractor's'Name icense No. �� WELL REPLACEMENT El DESTRUCTION TYPE OF WELL/PUMP: NEW WELL PUMP INSTALLATION ®--� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�.� PROP. LINE FOUNDATION _� J AGRICULTURE WELL OTHER WELL PITS/SUMPS — i 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial men Bottom 13 Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing F ublic ; 11 Other CD Delta Depth of Grout Seal .-® 'f' Type of Grout ❑ Irrigation a 2�pprox. Depth Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P. 677— State Work Done f Well Destruction LJ7�6iSealin Well Diameter 9 Material Itop 501 1. Depth Filler Material (Below 50'1 OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiwsh syavastem feetltted if public sewer is Installation wi Residence— Commercial_ Other 1 k Number of living units: Number of bedrooms ' Character of soil to a depth of 3 e Water table depth r SEPTIC TANK EI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal '1 Distance to nearest: Well Foundation Property Line 1 j 1 LEACHING LINE El No. & Length of lines _ Total length/size FILTER BED , Foundation arty Line ,. p Distance to nearest: Well w !� ;;r ' . - Number, .. SEEPAGE PITS "❑ Depth Size, - -- _ *s SUMPS r ,1 `, . . to nearest: Well Foundation ❑-..;'Distance Property Line DISPOSAL PONDS hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin`epunt ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . . ,z . Homeowner or licensed agent's signature certifies the following: "I certify that in the.Nerfarmance of the work for which this peim'i-is.issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califfirnia."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 mu call � r all required inspections: Co rowing on+reverse side. � I Signed V w TRle: — - — Date: /�� l }Fp DEPARTMENT USE ONLY GC.Cg Date A � rea ' Application Accepted by q� r �� - t Pit Grou spection by Date Final,lnspection by Date Additional Comments: ❑ 5tk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6 385 Q// = Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Halton Ave., P.O. Box 2009, Stk., A 95201 FEE AMOUNT DUE _.AMOUNT.REMITTED RECEIVED.BY11--0 -y.r-•DATE-, -- PERMIT'-NO- FEE INFO "CASH-7 G IL 76414� /TiZ 1K I- + EH 13-24(REV.10183) tD d57 06 r4 Vh- s EH 14-28 ... _.