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APPLICATION FOR PERMIT SAN JOAQUIN LOC ALHEALTH DISTRICT ,es t" 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209a)-466-6781 PERMIT EXPIRES 1'YEAiFROM DATE ISSUED (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. 1662 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r," City_90dkA z Lot Size PM Owner's Name Address /� Phone Y—S Contractor l Ad ss �G �L�l �� License . hon d3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. a PROP. LIVE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS t9�� G(�5 t'`1 f' rou 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5lJr d ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r FI Public ❑ Other ❑ Delta Depth o,�,Grout Seal -Type of Grout---_I Irrigation --Approx. Depth i I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction 1_1s� Well Diameter rt Sealing Material Itop 50') d ' Depth�4j)1 _ Filler Material (Below 50 s — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted.if public sewer is r available withM 200 feet.) Installation will serve: Residence_ Commercial— Other F 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. ❑ r Method Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BI=D ❑ Distance to nearest: Well Foundation Property Line m SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Weil Foundation >_ Property-l-ine I DISPOSAL PONDS ❑ . I hereby certify that I have prepared this application and that the work will be done in,accordance with San?Joaquinl,iNnty ordinances, state laws, nd rules and regulations of the San Joaquin Local Health Di§trict. "I . j ' Horne owner or licensed agent's signature certifies the following: "I certify that in the performaAd,&of the work for w ch thispermit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Californta.yContracto' rung or sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ per' s subject to workman's compensa- tion laws of California." f The applicant m tail for all required inspect! ns. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY � 2 Application Accepted by Date 7_ Area 0 Pit or Grout Inspection by fry Date �3_d�} ei Final Inspection by _.__._� c�Date Additional Comments: �� C g JL�A A F., — ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Mllnteca 823-7104 ❑ Tra 635- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED I CKCASH RECEIVED BY DATE PERMIT'NO. y�A ^r�� +.EH 13-241 REV.1/H 57 - J tKj�tat i ��' �� J� U I _4 i EH 14-2e