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■ APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appliaon is hereby /or install the work cation is madecnticompl compliance with SanoJoaqu the n County Ordinan Joauin lnce No.549 for sewage orealth District for a 'No. 1862 for weit to construct upump and the Rules and herein Regulations of he San l Joaquin Local Health District.79 n.y�0 � �/� 001(p— City of Size—. %e�Q� PM Job Address _— r,Q,A )��y. }i74s� g1� .v?I _1Y11S�Ilt/1ri^� -- Phone J Owner's Name r Address � Lee� - -- tractor Address icense fyo. � Phone TYPE OF WELLIPUMP: NEW WELL WELL RE LACEMENT ❑ DESTRUCTION� M�f7©l�l�P� 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 fr Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 i Specifications GIM04.17 FI Public —p1her nDelta Depth of Grout Seal Type of Grout - I I Irrigation 4OFApprox. Depth I 1 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION I I available septic system m per itled if public sewer is Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK ❑ 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 ust call for all required ins ctions. Complete drawing on reverse side. Signed X /1 r; "f _ Title: s M�1 rS Date: —1917 Ar V p � �5N7 �� C. f' 'if►�' 7/esfi�fs'P�i7 R P ENff USE ONLY 3 Application Accepted by Date:,/ Area Pit or Grout Inspection by Date - Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: EnvirVnmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA&H RECEIVED BY DATE PERMIT'NO. INFO _J_ + EH 13-24(REV. /H s) � tea[ )/q r 190— 1 S.� EH 1a-29