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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: Job Address Qe� City -.Q Lot Size PM _ Owner's Name f t Cz/� �A`y0 ddress +4'1/IVB'!/�-' _ Phone Contractor /'"!Q� ld;5 �ddre s �� License No, r� >� Phone J TYPE OF WELL/PUMP: NEW WELL,' WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. 642�t .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ /s— AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing Domestic/Private. . VGravel Pack ❑ Tracy Type of Casing Specifications - M Public ❑ Other Cl Delta Depth of Grout Seal `40 Type of Grout dqVoF, 1 1 Irrigation f Approx. Depths�I. I Eastern Surface Seal Installed by )✓ /!/4/ l' Repair Work Done El Type of Pump v H.P. _- State Work Done_ V �P - Sealing Material Ito 50'1 o - Well Destruction � Well Diameter g p Depth _ �+�� _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IT -REPAIR/ADOITION f I DESTRUCTION I I (No septic system permitted if public sewer is k available within 200 feet) hR 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 r ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ T 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." Contractors hiring or sub-contracting signature 'k 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 r al rer�tr ctions. Complete drawing on r 7se/de. Signed X Title: Date: FOR DEPARTMENT USE ONLY Ir'+, Application Accepted by _.-. _. Date ~�� Area �.' Pit ar Grout Inspection by Date Final Inspection by D to " a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, S[k., CA 95291 i? FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO- INFO A +.EH13-24(REV.1/n51 �� '1 - (, - - 9 �� V `�f27 EH 14-28 V91-11079 i .