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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-63%`16 r- 2 G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. Job Address "I City J Lot Size PM Owner's Name Address Phone taL—T�� Contractor 1 °`' ►'.�c �Address t License No& Phone TYPE OF WELL/PUMP: NEW WELL 2C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC'TANK /Oil � SEWER LINES . a�— DISPOSAL FLD. ` PROP,. LINE a u Ir FOUNDATION qO AGRICULTURE WELL OTHER WELL.. PITSI:SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava 'on Z 0 Dia. of Well Casing M I Domestic/Private JK Gravel Pack ❑ Tracy Type of Casing r Specifications I'1 Public - � ❑ Other Cl delta Depth of Grout Seal Type of,Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by — ' - Repair Work Done .❑y Type of Pump ' ' +r H.P. T State Work Done � � wy Well Destruction ❑ � Well Diameter: 1�. Sealing Material (top 50') Depth,------•-- Filler Material (Below-501)' -TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I' DESTRUCTION l I INo septic system permitted if public seweris "-" available within 200 feet.I Installation will serve=s:Resiaenc_6 Commetcial _Other----------_. e' - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth' SEPTIC TANK ❑ Type/Mfg Capacity i- -_No.,Compartments I PKG. TREATMENT PLT. ❑ ;. Method of Disposal Distance to nearest: Well Foundation 'Property tine t t S LEACHING LINE ❑ No. & Length of lines Total length/size iv..,.: 1 FtLTER BED ❑ Distance to nearest: ' Well Foundation --Property I''ine—i ii SEEPAGE PITS I 1 Depth Size _ Number 1 SUMPS L-1 Distance to nearest: Well Foundation Property Line 1 l DISPOSAL PONDS ❑ I i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cohnty ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-work forrwFiicti 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`hi`ri�r 9-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." 1, The applican stc I�1 for all,requ(i�e/q�1 inspections. Complete 1drawing o averse side. s f(�j Signed X. r/�-C�t> `" `� v'r `title: Date:' J 9 FOR DEPARTMENT USE ONLY Application Accepted by�~ date Area Pit or Grout Inspection by 3 Date-- Final Inspection bye �� Date j i Additional Commenta:' -.��._.._., .-�:, , El Stk 466-6781 ❑ Ladi-`3tu'3&21� ID Manteg 3-710_4 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO C p y �.EH 13-24(REV.tix5] /QSe - EH 1l-28