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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 ffln Aft PERMIT EXPIRES 1 YEAR FROM DATE ISSUE tU V ENED (Complete in Triplicate) AUG 0 3 192 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t►►h�et{work �h�erreiinn described,rThis^a�pr�plication is p ty 9 ENV9R0E%TAt[orH k'Ai2 t•'t`�Joaquin made in com liance with San Joaquin county Ordinance No.549 for sewage or No. 1(362 for well/pump a Local Health District. PERM I T/SERVI�EJ Jab Address .- - _ LAA'(; City Lot Size PM Owner's Name Address Phoneal — �3 4 Contractor Address License No.&(� Phone 4,��x .TYPE.OF.WELL/PUMP: NEW WELL.-..❑_ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ar OTHER ❑ 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 Dia. of Well.Casing 1:3 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation g )i�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (I Public FIOther ❑ Type of GroutDelta Depth of Grout Seal — I 1 Irrigation -APProx°DBPth . l Su ace Seal Installed by � _I Eastern )I� I Repair Work Dour; L-1Typeof Pump � {� H.P. State Work Done�. Well Destruction ❑ Well Diameter 6 d Sealing Material (top 501 l Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Characterof ss Tl 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well RFoundation Property Line SEEPAGE PITS I I Depth f Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line - —DISPOSAL PONDS------D 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 fot! g: "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 law 'fo ia." The applic st coil for all re 'ed inspe ti ns. Complete drawing o r Aside. Signed X Title: Date: FOR DE ARTM LY Application Accepted by Date Area Pit or Grout Inspection by, Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-6385 Applicant - Return all copies to: Environmentaf Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH If RECEIVED BY DATE PERMIT'NO. , INFO + EH 1321(REV.1/N5Y k�� �F � 91— Q � r EH 11-26