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I I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) .Application is hereby made to th'e 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. it Job Address 1 City 61� of Size PM L-7- Owner's Name Address u� Phone C tractor Address License No. Phone_ TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO. - PROP. LINE FOUNDATION RICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLENEAN STRUCTlON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantof Well Excavation . Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac of Casing Specifications l'7 Public Cl Other ❑ el h of Grout Seal Type of Grout 11 Irrigation 1Approx. Depth I Easteace Seal Installed by _ Repair Work Done ❑ Type of Pump. State Work Done Well Destruction ❑ Well�Diameter l Stop 50'1 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION [No septic system permitted if public sewer is i available within 200 feeL1 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ h Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ! 7 FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line }�+ SEEPAGE PITS ti Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El !I: 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, 1 shall not employ any person in such mariner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies the following: "I certify'Ithat 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." �I The applicant must gall)for ail required inspections. Complete drawing on reverse side. Signed X(o yrat;" ff Title: In s, Date: FOR Q1rPARTMENT USE ONLY Application Accepted by Date a Area Pit or Grout Inspection by '� Da Fin I Inspection by Date Y r ( I / Additional Comments: � ' � 'U W /�7� ElStk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6315 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. i` 35•@v 13H 1324{AEV.tiMel y_87 -r-zyy EH 14-2a J