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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 County Ordinance No. 549 for sewage or No. 1862 for weWpump and the Rules and Regulations of the San Joaquin Local Health District. �pJob Address [./' + `�'GI� Citffemv 6 Size /P, Owner's Name Ad�e��/�J Phone �l 3 7�8 Contractor _6M S_� Address &Ask Z3 elemex� License No' L177— Phone�j�✓7U9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR ❑ ��TH��,, �,� OTHER El DISTANCE TO NEAREST: SEPTIC TANK // SEWER LINES DISPOSAL FLD.� PROP. LINE �y�* AW FOUNDATION AGRICULTURE WELL ,. OTHER WELL ..sem PITS/SUMPS �G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d� Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ?omestic/Private 61G ravel Pack ❑ Tracy Type of Casing Specifications omestic/Private /�� (1 Public n Other Y F1 Delta Depth of Grout Seal O T pe of Grout �S,/4-- I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump M.P. State rk Done_ a Well Destruction Ll Well Diameter Sealing Material (top 50'I Depth Z�_ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I ) DESTR CTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 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 >1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WelkFoundation Property Line v LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:' Wel! Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line p��] 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,.) shall not employ any person insuchmanner 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 Califor is The applicant it inspec' mplete drawing on reverse side. �} r �_ p7 Signed X `�` Title: MIX-021 Date: H o FOR DEPARTMENT USE ONLY A- plication Accepted by Date 01 (�,L Area Pit or Grout Inspection by Date / ( Final Inspection by Date 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 20W, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVEDBY DATE PERMIT NO. INFO CASH �J J l: a.EH 13-24 1REV.1/m 51 /} G r EH 14-26 v Y ! k - Il•