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Cf APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone(209) 466-6781 PERMIT EXPIRES YYEAR FROM DATE ISSUED C'�1�^"� (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, ��'' // n/ Job Address S_ Q�T _ _— City _�tr ..— Lot Size _ PM Owner's Namef�L1l,� — Address .��r. L—(� ��'/hCG-__ Phone Contractor IL_. __Address _ License No . - Phone 20 ,TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT ❑ DESTRUCTION 1771 PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ ROP. LINE FOUNDATION .__ AGRICULTURE WELL' OT _ L -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS N SPECIFICATIONS_ 1 ❑ Industrial ❑ Open Bottom CI Manteca ia. of Well Excavation _ _ Dia. of Well Casing O Domestic -1 Gravel Pack cy Type of Casing_ . _ Specifications - 1-1 Public (`I Other I- Delta Depth of Grout Seal Type of Grout _ I I Irngation pprox. Depth I I Eastern Surface Seal Installod by - -- - Repair Work Don Type of Pump _— H.P. State Work Done — Well Des ion U Well Diameter _- Sealing Material (top 50'! Depth Filler Material (Below 50.) _ _ - TYPE OF SEPTIC WORK: NEW INSTALLATION (.l REPAIR/ADDITION I I DESTRUCTIO (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 .. _. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line_. LEACHING LINE n No. & Length of lines __.__ Total length/size FILTER BED fl Distance to nearest: Well Foundation ._ .. Property Line i I SEEPAGE PITS ( I Depth . Size __ Number SUMPS L! Distance to nearest: Well Foundation Property Line .1 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."Contractors hiring or sub-contracting signature curtifies 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 cull fo It r quir inspections. Complete drawing on reverse side. S �J Date'! 17 �IDEPARENT USE ONLY Application Accepted by �LU, z!`r�` a�L z✓� Date 0 1 Area y Pit or Grout Inspection b Date Final Inspection by04OateJL Additional Comments: ❑ Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 7104 Ll Tracy 835-6385 q-�_ ,zQi g, .Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 !� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO _ ,w,ll . EH 1324 IREV.i/h-1 V U !/-' U V EM 14- � 2e I-� •�