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. Y 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. Tins application r E made H compliance with San Joaquin County rdinance No. 549 for sewage or Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s , Job Address 1s. 11 City .L1 Lot Sizeo ?rC-iCLPM t Owner's Name Address - 4 1 1 Phone Contracto ss TYPE OF WELL/PUMP: !_;cense No Phone NEW WELL WELL REPLACEMENT ❑t PUMP INSTALLATION DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK ILI b� SYSTEM REPAIR.❑ OTHER ❑ — � SEWER LINES °bISPOSAL FLtyvQ c� FOUNDATION �jAGRICULTURE WELL 8 PROP. LINE OTHER WELL INTENDED USE f �PITS/SUMPS Q)4)C 1 { TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I�❑ Industrial ❑i Open Bottom Q_Manteca.., Dia. of Well Excavation g f Domestic/Private : 'Grave! Pack ❑ Trac Dia. of Well Casing ❑ Public k Y Type of Casing r' 4 ❑ Other t ❑ Delta L Specifications ❑ irrigation Depth of Grout Seal _ �[} r t ---Approx. De th ❑ Eastern Type of Grout Repair Work Done�'D T p u ace Seal Installed b Type of Pum j y H.P. `f _ rJ�J► Well Destruction '❑ Well Diameter State Work Done Sealing Material (top 50'1 1 t Depth t ---Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑�to septic system permitted if public sewer is 1 Installation will serve:' Residence, available within 200 feet.) Commerciy Commercial_ Other Number of living.units: Numbe; of bedrooms Character of soil to ai depth of 3 feel: SEPTIC TANK ❑ Type/Mfgf Water table depth r\� i ' PKG. TREATMENT PLT. ❑ F Capacity No. Compartments Distance to nearest: Well Method of-Disposal Foundation Property Line LEACHING LINE ❑ No. g, Length of lines ` FILTER BED ,M []._.ppstancd to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth U1 Size Number r1 SUMPS ❑ Distance to neatese : Welln DISPOSAL PONDS ( L2Foundation Property Line r`r 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 O rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: � employ any person in such manner as to become subject to workman's compensation lawsoof California." Contractormance of the work for r'sIh ringch /or sub-contracting signature certifies the following: I certifythat in the performance of the work for which this permit is issued, I shall employ permit is issued, I shall not ., tion laws of California." p p Y persons subject to workman's compensa- tion applica st call'for all required ins ctions. Complete drawing on reverse side. Signed X Title: Date: F R DEPARTMENT USE ONLY Application Accepts y ! - 7�G Pit or Grout Inspection b �� ✓ " Date Date Final Inspection by Area 6(aDateComments: l/t/Y� Date ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tI £ 1 FEE AMOUNT DUE I1 INFO AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.iias) EH 14-2e V-711 1 'E �J��l� b 7 I.S