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k - APPLICATION FOR PERMIT 'S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4, (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 Coulaty Or iqa a a 54 f�° sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / ��/� e1 'eida :�-Ci. �I�_ � Job Address G� City A eLot Size PM Owner's Name •8• A4C ~C KL Address f9ZvCqyro1S phone,_rAr / SS 5Z Contractor ICf t ' Add ressZ Z 6o 0 esf 4 License No.S Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LlSYSTEM REPAIR C1OTHER ;wS 77441f b06W DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Other ❑ Delta Depth of Grout Seal T peL of Grout f I I Irrigation --Approx. Depth I 1 Eastern _ Surface Seal Installed by— Repair y Repair Work Done ❑ Type of Pump H.P. State Work Donelb le 4 V ►� Well Destruction ❑ Well Diameter Sealing Material (top 50') G Depth Filler Material (Below 501 – Q' TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) i 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 PKG. TREATMENT PLT. Ll Method of Disposal 4 Distance to nearest: Well Foundation Property Line WI LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number i SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 sub-contracting signature certifies the following. "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's co mpensa- tion laws of Califo ia." The applicant c for all req ' d in t s. Complete drawing on r rse side. / q r Signed X Title: rry Date: t FOR DEPARTMENT USE ONLY li � Application Accepted by Dat Area Pit or Grout Inspection by Pate Final Inspection by Date . Additional Comments: Ll Stk 466-6781 ❑ Lodi A-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT'NO. i INFO a.EH 13-24(REV, EH 14-26 I Cd i