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APPLICATION FOR PERMIT # t SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 � +. PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) # Application is hereby made to the San Joaquin Local Health District for a pernik 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District- Job Address �! Z Zr�4 *' —' — -� p City/- Lot Size PM Address 7 L�[J [! lC.� Phone I Owner's Name _ _ 1 /f .� Contractor � VC7e' tAd ress , � cense No. 7 11 Phone 79 g TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO-.NEAREST:-SEPTIC,TANK-� SEWER_LINES_-------------_., DISPOSAL-.F.LD.� ---- - ..PROP.-.LINE� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ElTrac—TyPe of Casing Specifications ❑ Public f ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION ❑ DESTRUCTION , av1ailablerwit m 200ffeetitted if public sewer,is ii 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 i ; SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. L11 Method,of_Disp"osaI Distance t.o nearest: Well Foundation Property Line LEACHING LINE ❑ No.,& Length lines Y Total IengtFi/size FILTER BED E] Distance to nearest: Well Foundation + Property Line SEEPAGE PITS ❑ Depth t I Size i Number SUMPS E3 Distance to nearest: Well t Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thatythe-work.wiill be.done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 11- 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 ap n must call for a require i spections. Complete.drawing on reverse side. DD 7 7 i Si ned Title tTv+lf(!�-l� .Date: 9 FOR DE TMENT USE ONLY Date J/ rea } Application Accepted by Date..' A I. Pit or Grout Inspection by Da Final Inspection by TIJDate `LI S Ha { LhVVA� Sa f Q� •� � Additional Comments: s ❑ Stk 466-6781 ❑ Lodi 369 t ❑ Manteca 823-7104 t3 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 CASH RECEIVED BY DATE PERMIT`N0. INFO ` +EH 13-2IREV.1/s5) _ - EH 1428 `