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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) l l IApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicatl1 made in compliance with San Joaquin Coun Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health Dis 'c / s Job Address I 2.5 �r City Size PM 3V X, f Owner's Name Address Phone (� Contrac f ess License No Phoneg7 9/ �5 TYPE OF WELL/PUMP: _ NEW WELL ❑ ,WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 ❑ Tracy Type of Casing Specifications [-I Public f} Other ❑ Delta Depth of Grout Seal Type of Grout. I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by _ A Repair Work Done ❑ Type of Pump i H.P. State Work Done_ 'Well Destruction ❑ Well Diameter Sealing Material Itop 50') R Depth Filler Material (Below 501 V 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION S.I DESTRUCTION No septic system permitted if public sewer is - available within 200 feet.) 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 ❑ Type/Mfg : Capacity No. Compartments O PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line R LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: -Well Foundation Property Line 4 F SEEPAGE PITS Depth, Size Number rc SUMPS Cl Distance to nearest: Well Foundation Property Line I' 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. r� 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 v 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must cIfo ns. Complete drawing on averse side. i Signed X Title: Date: FOR DEPARTMENT USE ONLY tQ Application Accepted by Date ^L` Area N. I • Pit or Grout Inspection by Date Final Inspection by ice/"/ L Date r -�� Additional Comments: o ld �I / _V - 5'2f, .59)l ❑ Stk 466-6781 ❑ Lodi �&21 "❑ 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 MOUNT DUE AMOUNT REMITTED CK RECEIVED BY BATE PERMlYNO. INFO CASH may. a EH 13-24(REV.I/K 5) U5$ 1 NA&0 — ! EH 14-28 C t (J