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APPLICATION FOR PERMIT T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) M Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is i made in compliance with San Joaquin County 0rdin nce No.549 fn se age or No. 1862 or well/pump and the Rules and Regulations of the San Joaquin Local Health District. 27 /fjl f `jt�3 O C q 4� "�� Job Address r y Lot Size a ' PM p/ 10 Cccr=6S Owner's Name' tai a _: Address !p- 16]G f tom►/��1 �'. C[ Phone 5raa3 Contractor__Le.AAddress License No. Phone TYPE OF WELL/PUMP: NEW WEL WELL.REPLACEMENT Ll DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial Cl Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public I-1 Other fn Delta Depth of Grout Seal Type of Grout _ I I Irrigation j_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction CJ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 YPE OF SEPTIC WORK; NEW INSTALLATIOWV' REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is j . available within 200 feet.) i Installation will serve: Residence Z` Commercial_ Other Number of living units: Number of bedrooms i . Character of soil to a depth of 3 feet: # L O vtn Water'table depth AM SEPTIC TANK ❑ T e/Mf :- rt `r}y ��, YP g CapacityJ ajQ No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well ,y.,.� Foundation t —�tL� � Property Line �d -- ( LEACHING LINE ❑ No. & Length of lines d Total length/size T FILTER BED D Distance to_nearest: Well t Foundation I� _ Property Line C j r i SEEPAGE PITS 1 ) Depth Sire _ Number SUMPS L� 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 Diatrict. 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 applic nt must cal for a eRe-E empleto drawing� �rorn�reverse side. Signed X y Title: V Date: 1l FOR DEPARTMENT USE ONLY Application Accepted by e', �, Date f Area . i Pit op - inspection byDate Final Inspection by Date` 4 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 95291 FEE• INFO AMOUNT DUE AMOUNT REMITTED RECCASH EIVEp BY DATE PERMIT'NO. � ` r .,EH,11-28 3-24 lREV. EH ,iHai (� © � r �71�1 I S9 -30;X,9