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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT `S-u- 1601 E. HAZELTON AVE., STOCKTON, CA l C- N0� &V1?Z'A11 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 No.549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9 I ,[� }l Thy/ 9 Job Address � / O /P i! City `�` v4`zJ Lot Size ` C/ PM - '��} �f Owner's Name 7t '�Gr Address ` 14 ! e? AV�� Phone Contractor IT i_ - !/ Address 114�Q YC u �&icense No.��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP iiRSTAQATION ❑ SYSTEM REPAIR" El ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP At"FLD. PROP. LINE FOUNDATION RICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell'Excavation Dia. of Well Casing ❑ Domestic/Private>LJe l Pack ❑ cy Type of Casing Specifications ❑ Public ❑ Delta Depth of Grout Seal Type of Grout I Cl IrrigationDepth ❑ Eastern Surface Seal Installed by Repair Work DonePump H.P. State Work Done Well Destructionmeter Sealing Material (top 501 Depth Filler Material (Below 50') 9 s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l 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 I SEPTIC TANK ❑ Type/Mfg y Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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, I shall employ persons subject to workman's compensa- tion laws of Califo is ' The applicr pcm wingSverse side Signetle . T Date: FOR P EiHT USE ONLY ^� "'7 D Application Accepted by F Date Area Pit or Grout Inspection by Date - Final Inspection'by Dat.7Z 3- Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 0.Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /+DATE PERMIT'NO. + EH1144-28-241pE't/.iias) Qe� UO EH �` 0770-1-JI �J'�