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t 5 .. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA /Py Telephone 12091 466-6781 149 a �v 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 herbAMsc . This applia*on is made in compliance,with San Joaquin County, Ordinance No. 549 f6r,sawage or No. 1862 for well/pump and the Rules and an Joaqui r _ Local Health District. f2 D(a� ti� �� /.r 44 ,� P .tel[ a. /�%%LC • A)m Y- . o � �r;.. � i � n ORA � IV Owner's Name > L Address X Tlid Phone Contractor's Name ':icense No. 0 0 Phone 6 -113P6 TYPE OF WELL/PUMP: NEW WELL , WELL REPLA IAENT DESTRUCTION El PUMP INSTALLATION El SYSTEM REPAI ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK, SEWER LINES DISPOSAL FLD. /,,+ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL__'$�f PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBL€M AREA± CONSTRUCTION SPECIFICATIONS ,r ❑ Industrial ❑ Open Bottom ❑anteca Dia. of Well Excavation . Dia. of Well Casing �bomestic/Private W'Gravel Pack W-11 racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Jt Type of Grout ❑ Irrigation ---.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: - NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (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 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 call fo'r all req 're spections. Complete drawing on reverse side. Signed a / Title: V Date: �7/,N OR DEPARTMENT USE ONLY Application Accepted by `� � � Date 1`�%_1r_ �f Area O Pit or Grout Inspection by Date /Final Inspection by Additional Comments: C77)._Q —S., y -4a, ., r -LU i,,, A YJ -Z2,\ \..- -�r ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ cy 8354KM Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y + EH 1324 (REV. 10/9 EH 14-26 Date FEE INFO AMOUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE PERMIT"N0. Gy, A3H�7 � 4-154