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r. t APPLICATION FOR PERMIT 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) 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 r sewageorNo. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f'�b r_ - Job Address City et Size PM E Owner's Name t,e 4' Address Phone 474 M Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal 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 L1 DESTRUCTION ID (No septic system permitted if public sewer is "."l available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: --I— Number of bedrooms { Ch;racter of soil to a depth of 3 feet: o � Q2JyWater table depth Z.Z SEPTIC'TANK ❑..�fype/Mfg Capacity rJ0 No. Compartments '2– PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well `-' Foundation Property Line s� r LEACHING LINE (- No. & Length of lines C ?o Total length/size _ I FILTER BED ❑ Distance to nearest: Well �� Foundation �� Property Line S I SEEPAGE PITS 4 ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line I f DISPOSAL PONDS ❑ f 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. I I *`. .1 Home owner or licensed agent's signature certifies the following: :'1 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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ` certifies the following: I cern that in the performance of the work for which this i g:" certify permit is issued,I shall employ persons subject to workman's compensa- tion laws of Ca' rnia." _ The applican ust call far all r q red inspections. Complete drawing on reverse side. _ Signed Title: Date: OR DEPARTMENT USE ONLY i 2-1-e6 Application Accepted Date A f Y7 6 Area Pit or Grout Inspection by Date Final Inspection Date " Additionai Comments: ❑ Stk 466-6761 ❑ Lodi 359-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI/ITT"NO. + EH 73-24IREV.1/85> �� /�QO '4 fj� �i[/`��" �� ?V L '-3 EH 14-28 f/� V