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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t� 1601 E. HAZEL T ON 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 Coun Ordinance No.549 for se age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City,__�4411Lot Size P M _ Owner's Name ddress 7-M6� Phone .3r Contractor dress/ / icense No. J! Phone �� : TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE TSN FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OR1 ❑ 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 Type of Grout I I Irrigation _-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction '❑ Well biameter Sealing Material (top Depth Filler Material lBe!pw I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 11 DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feed Installation will serve: Residence_ Commercial_. Other .-a Number of living units: _L_ Number of bedrooms �_J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 60 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth It Size Number SUMPS L-7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "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, I shall employ persons subject to workman's compensa- tion Laws of California." , The applicant ust ! f r all re i ed inspectio sl mplete drawing on r verse side. Signed X Ti 14 V 071�7 _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by A A j4 Date-7 Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY DATE PERMIT*NO. INFO CASH N 0 + EH13-21(REV.I/115) ®"o "70 EH 14-29 /3/� 2-tV-Jv 3