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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM 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 incompliance with San Joaquin County Ordinance Not 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. t �f �,� X r A f� C� City 3 tV .Lot Size PM i Job Address �rE Lf �Q 'TC ICA-LC-2F' Phone � v3*L7 Owner's Name TIC Address !! ty Contractor C GR�sr —Addressi�013 IN oo License No 7M' Phone Z TYPE OF WELL/PUMP: NEW WELL AWELL REPLACEMENT ❑ DESTRUCTION ElPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑' ./. DISTANCE TO NEAREST: SEPTIC TANK 1110 SEWER LINES DISPOSAL FLD. PROP. LINE 1� FOUNDATION AGRICULTURE WELL OTHER WELL . PITSISUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing ✓CSpecifications M 1 Other Ll Delta Depth of Grout Seal -s o Type of Grout C h F7 Public 04% I I irrigation 1"_Approx. Depth 1 I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump _„�y d-.--- H.P. ;o� State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material-IBalow 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION L1 DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence ' Commercial— Other t Number of living Number of bedrooms Character of soil to a dept feet: Water table th SEPTIC TANK ❑ TypelM Capacity N impartments I Method of Disposal PKG. TREATMENT PLT- ❑ , Distance to nearest: We Foundation Property.tine r LEACHING LINE ❑ No. & Length o1 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation operty Line SEEPAGE PITS 11 Depth Size Number SUMPS L-1 D e to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l Thereby 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 persop.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." ± d inspections. Complete drawing on reverse side. The applicant must call for all require Signed.X - -_ Title: 92t A rh Date: I OR DEPARTMENT USE ONLY y - `-v � Application Accepted by Date Area Pit or Grout Inspection by f Date-i/ /a' Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED CK T-7 CASH RECEIVED BY DATE PERMIT'NO. /� ♦.EH 13-24 1REV. /�/� /7�'�/ ��/ EH 14.26