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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) • ,o - t k Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This appfcation is made in compliance with San Joaquin County Ordinance No.549 for seikage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i. Job Address / City / /'�- Lot Size. PM Owner's Nameer r w. Address _G/ — Phone Contractor's Name License No. Y, Phone i/0' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing _ ,a-f Specifications 0 Public ❑Other - j` ❑ Delta Depth of Grout Seal 4 I r Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ' 4 Repair Work Done ❑ Type of Pump H.P. f �StateVork Done � i � Well Destruction C4( FWell Diameters - ,Sealing Material {top 50'1 f Depth -4 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION W(No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other �-.��. !�®,S,,►gra, Number of living units:. Number-of.bedrooms Character of so!]to a depth of 3 feet Water table depth SEPTIC TANK-' ❑ Type/Mfg' "`"" Capacity No. Compartments PKG. TREATMENT PLT. ❑_ L ;,. j Method of Disposal ! ` yy Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length.oflines Total length/size 'FILTER BED ❑ Distance to nearest: Well f" Foundation Property Line SEEPAGE PITS ❑ Depth Size ! Number j SUMPS C7 Distance to nearestWe11 Foundation Property Line DISPOSAL PONDS ❑ �l } 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 - : -. 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'w rkirian's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol g:"I certify that in the performance of the work for wh` permit is issued,I shall employ persons subject to workman's compensa- tion laws o alif nil. The appli st cal!for all r pections. Complete drawin o r side. �� `` ` 5' ed Itle: Date: �— { r .� O EPA MENT USE ONLY Application Accepted by Date Area ZoPit or Grout Inspection by Date Final Inspection by Date~ Additional Comments: q ❑ Stk 466-6781 - -0 Lodi 369-3511 � 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 - t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13.24IREV.101831 ,—7s'A 0 EH 14-26