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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th work herein d scribed. This app station made in compliance with San Joaquin County Ordinance No.549 f sewa or Na_ 1862 fpr well/ ump d RP nd R ulations of the San Joaquin Local Health District. Job Address /11/ City Lot Size v aY ` ' PM Owner's Name F .*: _Address ;j/.'? 1"✓ s Phone�� J Contractor// t dress ! / License No., Phone 'TYPE OF WELL./PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑.# i 7 i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ b DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' �. f FOUNDATION[ AGRICULTURE WELL OTHER,WELL + PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Pack ❑ Tracy - -�' Type of Casing Specifications # f`7 Public L7 Other ❑ Delta o Grout Seal Type of Grout { j"-4 _ "I Irrigation _._Approx"Depth Surface Seal_Installed by Repair Work Done ❑ Type of Pump H.P. ` t S�tat, �Dne Well Destruction ❑ I, Wel eter _ Sealing Material Itop 50 7f / Depth __.-Filler Material IBelow 50') t TYPE OF SEPTIC WORK:---NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION 14 (No septic system permitted'if public sewer is available within 200 feet.] r Installation will serve: Residence_� Commercial_ Other - p '.,.."Number of,living units:'- Numb&of bedrooms Character of soil to a iiepth`oT3 feeet:" It " " -� r Water table depth t 1 SEPTIC TANK ❑ Type/Mfg Cap i T No. Compartments` t f PKG. TREATMENT PLT. ❑ Method of Disposal ,. 4 w"-Distance to nearest:-- Well-^ ! Foundation.. Property Line f LEACHING LINE ❑ No. & Length of Ii Total length/size i [-FILTER BED ❑ Distance to near t: _ tion Property Line '' SEEPAGE PITS I 1 Depth Size Number 1 SUMPS LJ Distance to nearest: Well/ �-O Foundations Property Line" S t DISPOSAL PONDS ❑ _ 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 parson 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." _ I The applicant ust call far al required i spections. Complete drawing on reverse side. _. .... Signed Title: r Date: I' E FW-.DEPARTMENT USE ONLY rs • t� Q�_ Application Accepted by F A :•. �:• "Date _,1 �1�L Area Pit or Grout Inspection bv ` Date Final Inspection by �- �1"c_.J[�S�L Date Additional Comments:.. 9y * ❑ Stk .4&-6781y-, [�.Lodi^'369-3621 ❑ Manteca 823-71b4 5 Tracy 835-6385 x Applicant - Return all copies to: Environmental Health Permit/Services 1601 E`Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 IN_Fb MpUNT bUE} AMOUNT REMITrEb GASH'S , RECEIVE[) BY, .DATE _ PERMIT.NO- }� y,• i ' �. a EH 13-24 IREY, as s EH 1 4-28 r -- - -s .(f V� F.U�w- - _• . _ -