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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f PERMIT EXPIRES 1-YEAR FROM DATE ISSUED #j {Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in made in compliance with San Joaquin County Ordinance lth District for sewage a a or it t 1 on for well/ um ty stall the work herein described. This application n � t Local Health District, g p p and the Rules and Regulations of the San Joaquin Job Address So, �� 3L City T Lot Size &!!eto PM Owner's Name //0404 �(� �� Address . j � -•- --._ . � _ _ Phone Contractor ,VIX 0, Addressd4px B y TYPE OF WELL/PUMP: �� f�Q icense No:'�'�yt�' 7f NEW WELL O �: WELL REPLACEMENT ❑ — —`—Phone -5/.?j� PUMP INSTALLATION ❑w-�- DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SYSTEM REPAIR'© OTHER O ` —� SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTUREWELL PROP• LINE'. INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial LiOpen Bottom -~� ca ^- ❑ Manteca Dia. of Well Exvation ❑ Domestic/Private ❑ Gravel Pack ❑ TracDia. of Well Casing y Type of Casind' + M Public n Other } Depthof Grout Seal ' S ecifications . Delta I I Irrigation ❑ k ' � ti Type of Grout ;L of pump Depth l 1 Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pum r -"' p H.P. {( Well Destruction ❑ Wel! Diameters _ State.Work.-Done -� 1 Sealing Material trop 54'p '+ . Depth iFiller Material iBelow So') 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE1. PAIR/ADDITION Om DESTRUCTION I I tNo septic system permitted if public sewer is Installation will serve: Residence-L; available within 200 feet.) (n Commercial Other Number of living units: Number of bedrooms--*' Character of soil to a depth of 3 feet: drawy. tt ' SEPTIC TANK Water table depth t ere ❑ Type/Mfg ?(' Ce•}�'r Capacit . ./..r?Db • PKG. TREATMENT PLT. ❑ ° y=--- No. Compartments �. Distance to'nearest: Well Job ` t Method of Disposal r Foundation fs� - Property Line cl LEACHING LINE ❑ No. & Length of lines FILTER BEDS _ t Total length/size r ii� Distance to nearest: Well !6d Foundation f:�� - -- _ —.Property Line F`1 SEEPAGE PITS i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well ^an, a DISPOSAL PONDS [] Fouridation 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 I 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 an 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 parsons subject to workman's compensa- tion laws of California." The applicant mu call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by w ' Date Final Inspection by Additional Comments: Date t ❑ Stk 466-6781 ❑ Lodi 369-3ti21 ' \ � ❑ Manteca 823-7104 Cl Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED H RECEIVED BY DATE PERMIT'No. + tiH 13-24,REV,i FH 14-25 M b