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r APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZEL T ON AVE., STOCKTON, CA 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 9Drsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health pistrict. /Agri co' /1 P-p r . � Lt Job Job Address -- 7 'Ya f. �l'7X f�(/ G]� _ _ City j Lot Size PM_ Owner's Name U Address - +,. Phone / 2• Contractor. r Ct f tt,Q)(0/-- Address 64 License No. S Z't�-S L Phone TYPE OF WELL/PUMP: NEW WELL?Z, WELL REPLACEMENT ❑ DESTRUCTION ❑ d PUMP INSTALLAT i N C] SYSTEM REPAIR ❑ T OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK 'j SEWER LINES DISPOSAL FLD[�. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOIN5 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ':�(Qomestic/Private Gravel Pack ` 1T;acy Type of Casing C' Specifications ® V ❑ Public ❑ Other +, ❑ Delta Depth of Grout Seal ` Type of Grout r f 1-1Irrigation �Approx. Depth C1 Eastern Surface Seal Installed by ti f Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') v Depth r Filler Material /Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other g,. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth \` ` SEPTIC TANK ❑ Type/Mfg-k.- -. Capacity I No. Compartments V r PKG. TREATMENT PLT, ❑ f ., Method of Disposal } Distance'to-•nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER SED ❑ .Distance to nearest: -Well _ Foundation.. - :-- - . . Property'Line SEEPAGE PITS ❑ Depth Size Number SUMPS i ❑ Distance to nearest:- Well Foundation "Property Line 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 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 California." The applicant all for al eq d ' spections. Complete drawing on revArse side. Signed X Title: Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by // Date d '�J Area Pit or t Inspection by Date/O�—� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PER N0. INFO + EH13-24{REV.tia51 90 (' _ Cfh� _�� EH 1428 y 1 LriV7 /l`n'f