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h ? . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA n Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. , 9 City ,lob Address ' Lot Size_ PM } Phone Owner's Name. Contractor Address" License No. Phone TYPE OF WELL/PUMP: f 9 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION SYSTEM REPAIR F7 OTHER ID DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE i FOUNDATION AG-R__ LTU RE WELL OTHER WELL PITS/SUMPS �r INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 9 ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing Type of Casing Specifications ,#�1DomesticlPrivate ❑ Gravel Pack ❑ Tracy V tType of Grout---, F] Public 171 Other ❑ Delta Depth of Grout Seal I I Irrigation .-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ T,ype.of.:P.ump �State_Work Qone. I -may F1r1 4aEAL�.P/1.[ l ) Well Destruction ❑ Well Diameter • ",K�>,•Sealirig'Material (top 50'1 - � ---- Depth , Filler Material (Below 50'! — TYPE OF SEPTIC WORIt�A—NEW-INS'--ALLATION-i b I—REPAIRIA• �ION-H—r-DEST�RUC-T10N-t-•IW(No-septic-system-permitted if public sewer is available within 200.feet.) Installation will serveesiderice Commercial Other" -...— i Number of living units: 1 Number of bedrooms r ` Character of soil to a depth of 3 feet:� ^ Water table depth SEPTIC TANK r `#❑� Type/Mfg `^ Capacity No. Compartments Ii ^ Method of Disposal I PKG. TREATMENT PLT. ❑ .I, Distance to nearest: Well A1 Foundation Property.tine 1 #` LEACHING LINE ❑, No. & Length of lines Total length/size FILTER BED. Distance to nearest: Well Foundation Property Line \1 SEEPAGE PITS 'r:l 11 Depth ' Size Number + p �`fi - t SUMPS �JLl# Distance to nearest: Well Foundation P..roperty.Line-- SUMPS ine_ If DISPOSAL PONDS ❑, ' l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of,ahe'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, l 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 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." F The applicant rt or `II requirQ - s tions. Complete drawing on ers e. F i Signed X Title: 1 ' - — Date: s FO DEPARTMENT USE ONLY (� 1110 Date v~�q�b rea v Application Accepted by � Pit or Grout Inspection by .a Date Final Inspection by Dat D d Additional Comments: { 11 Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, Im CASH + j ♦.-EM 13-24(REV.iiH5Yt - X-I 4 9`7 EH 14-26 ^