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I � APPLICA'TiOI1FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;-M 4 (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 wage or No. 1662 for ell/p mp nd the Rules and Regulations of the San Joaquin r Local Health District. t' Job Address Q J �17171 Y % Q City 0 CDt Size PM Owne"r's Name Address ems= Phone _ . Y: n .t6nt actor Address `r =q License No. Phone t� TYPE OF WELL/PUMP:" NEW WELL ❑ WELL REPLACEMENT •❑',. DESTRUCTION ❑ 1 i 0� PUMP INSTALLATION ❑ SYSTEM,.REPAIA,�., t OTHER-❑n DISTANCE TO NEAREST: SEPTIC TANK SEWEfi LINES �,,,,,,,, DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL a PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack L1 Tracy Dia. of Well Casing 1Z Y Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation - --Approx.,De th Eastern Type of Grout t Su ace Seal Installed by Repair Work Done Type of Pump H.P State Work Don G. Well Destruction ❑ Well Diameter Sealing Material (top 501 fit i Depth Nk, k eFiller MatefiaC(Below 501 I TYPE OF SEPTIC WORK: -NEW-INSTALLATION-❑ REPAIR/ADDITION El -pESTRUCTION ❑ (Nb septic system permitted if public sewer is E available within 200 feet.) Installation will serve: Residence Commercial_ Other , Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ ..J Method of Disposal { Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines "'` FILTER BED Total length/size „ ❑ Distance to nearest: W611 °+ Foundation t"A - r Property Line SEEPAGE PITS Q Depth Shia Number SUMPS ❑ Distance toinearest: WellFoundation DISPOSAL PONDS Lir i Property Line 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: t em to an g: ,"1 certify that in the performance of the work for which this permit is issued, I shall not P Y Y 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." t The ap nt m t call for all re d ins ctions. plete drawing on re rse stde. Signed X F g Title: r 5 Date: d t FOR DEPARTMENT USE ONLY F Application Accepted byt I Data Area b 24- Pit or Grout Inspection by pate Final Inspection by Date Additional Comments: Ljq-yk ❑ 5tk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑.Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK 6 INFO ASH RECEIVED BY DATE PERMIT-NO. + EH 1 -24(REV.t i a 51 EH 144-28 ' w +