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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED # (Complete in Triplicate) t 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 City Lot Size_%. . PM Owner's Nam G Addrest2 2C� 5*s Phone y 711 Contractor Addres License N Phon F' TYPE OF WELL/PUMP: :NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -92 A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a � 5 ❑ Indus--trial pen Bottom ❑ Manteca Dia. of Wel{ Excavation Dia. of Well Casings � i�'DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public 71 Oyher L ❑ Delta Depth of Grout Seal Type ut _ I I Irrigation a-h-___Approx. Depth 1 ] stern Surface Seal Enstalled by Repair Work Done ❑ Type of Pumpij^� H.P. _ C2State Work Done T '� Well Destruction ElWell Diameter . Sealing Material (top 501 ` Depth Filler Material (Below 501 t r•f TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION l-1 DESTRUCTION { 1 INo septic system permitted if public sewer jw � available within 200 feet.) Installation will serve: Residence—a Commercial_ Other r Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ R* Method of Disposal T� r Distance to nearest: Well Foundation `Property Line LEACHING LINE ❑ No. & Length of lines flength/size}� g Total FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'r r 4 SEEPAGE.PITS I 1 Depth, +" *,Size—.�_ _ Number. A � Distance to _ Well Foundation Pr0 p rty.Line SUMPS ❑ T DISPOSAL PONDS ❑ f 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: `9 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 certifi�'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 must call for all required i6spections. C pl a drawing on reverse side., Signed X * s Title: Date f1 FOR DEPARTMENT USE ONLY f Application Accepted by r t Date 1 Area Pit or Grout Inspection by Data D .Final Inspection by. Date Additional Comments: ZOL,,Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE -kAIVft7UNT REMITTED Y CK RECEIVED BY DATE' PERMI7 N0. f r EH13-24(REV.