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APPLICATION FOR PERMIT SA .OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR_FROM DATE ISSUED (Complete in Triplicate) 4 Application is hereby made to the San Joaquin Local Hoeft 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,649 for sewage of No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Diisttrriic�tj ) r'` Lot Size1 QPM Job Address Ci Name f � `Address. owner's � Contriclor � Addres+Y "r �rt '� �L_License No. Phone TYPE OF WELL/PUMP:--:. NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications' ` F1 Public n Other n Delta Depth of Grout Seal Type of Grout 1 I Irrigation —Approx. Depth t I.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 -- " Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEIN INSTALLATION9 REPAIR/ADDITION t 1 DESTRUCTION t•1 (No septic system permitted if public sewer Is available within 200 feet.) Intel) 66n will serve. •Residence_ Commercial Other ' Number'of living units: Number of bedrooms l Character of soil to a depth of,3 feet: Water table depth_ / J t v SEPTIC TANK °❑ Type/Mfg Capaci No,Conipartrrteits . PKG.TREATMENT PLT.❑ f•> Method of Disposal Distance to nearest: Well tiN Foundation Property.Line t :LEACHING LINE ❑ No. 6 Length of line! Total length/size. s FILTER BED ❑ Distance to nearest: W Foundation Property Line , t S O�GE PITS [ I Deptf� Number "'' w' [_l Distance to nearest: Well" Found.ti. 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 ordinance§, state laws, and rules and regulations of the San Joaquin Local Health District. Home,pwner 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 pny 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 applic 7nuyt- II for6all requed inspections.� Signed X omdlete drawiDater n `on reverse side. / G r- J J ( t ^` Tit: � �" i L.�" f r� 1 FOR DEPARTMENT USE ONLY Application Accepted Date Area Pit r Grout Ins c' by r�Date Final Inspection b 't`� Datee°' f r 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 K RECEIVED BY DATE PERMIT"NO. yll INFO CASH ..EHt}24IPtN.tinbl EH 14 26