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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A:;. jp, 1601 E. HAZEL T ON AVE., STOCKTON, CA 5. Telephohe•(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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �r City w Lot Size,5--Aax PM Owner's Name t` Address<� �, iitrs�� Phone d. Contract) ori t ` "' P4� "R dress -License IVo Phone C TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEP-TIC..TANK,- ,,SEWER..LINES- .DISPOSALIFLD-. PROP. LINE FOUNDATION . AGRICULTURE WELL OTHER WELL PITSISUMPS , J L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial E3Open Bottom C] Manteca Dia. of Well Excavation �-yy��- �� Dia. of Well Casing i Domestic/Private t JKGravel Pack El Tracy Type of CasingaY Specifications F] Public C1 Other Cl Delta Depth of Grout Seal _ Type of Grout I I Irrigation- _Approx. Det`h I I Eastern S�face Seal Installed by Repair Work Done Type of Pump CI�m H.P. State Work Done _ Well Destruction D. Well Diameter Sealing Material (top 50') r d f ,f Depth c� ti�� Filler Material {.Below 50'1 1 (TYPE OF SEPTIC ORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION i I [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 r 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 '--_Feunda[iori' 7 Property Line C SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line A j DISPOSAL PONDS ❑ O 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,1 shall employ.persons subject to workman's compensa- tion laws of California." The applican call for all required inspections. plate drawl on rev se side. Signed X e: -- - � /r / ' I �� Date: r/ FOR DEPARTMENT USE ONLY Application Accepted by Dated �Z.► Area �q Pit or Grout spection by Date Final Inspection by Date , U f Additional Comments: AAyz ❑ 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 95201 INFO AMOUNT DUE AMOUNT REMITTED K H ft RECEIVED BY DATE Qp PERMIT'NO. v +.EH 13"241REV.1/n5) 1 �_ 16 35 Yg,., EH 14-26