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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZEL T ON AVE., STOCKTON, CA r\JD W, Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED N)0 Q rl (Complete injriplicate) Application is hereby made to the San J I 01, Local Health District for a permit to construe is made in compliance with San Joaquin County ordinance No- 549 for sewage or No. 1862 for well pump atnd the Rules and the workall rR gulationsof the Sandescribe . ThisiJoaquin Local Health District. i Joh Address ,d � 1>7 �' Ci Lot Size PM � � 1` Owner's Name � i \ d re Phone I Contractor Address License No. Pho TYPE OF WELL/PUMP NEW WELL E3W L REPLACEMENT Elne DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation El ElGravel Pack Dia. of Well Casing ❑ Tracy Type of Casing Specifications I Public C1 Other F] Delta Depth of Grout Seal I I Irrigation —.-Approx.-Depth I i Eastern Surface Seal Installed by Repair Work.Done ❑ Type of Pump H.P. State Work,Done_ Well Destruction ❑ Well Diameter Sealing Material )top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC_tiNOAK: NEW INSTALLATION I:1 REPAIR/ADDITION i I DESTRUCTIO - y (No septic system permitted if pk.lbiic sewer is Installation will serve: Residence- Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: , Water table depth �_ SEPTIC TANK ElType/Mfg f PKG. TREATMENT PLT. LlCapacity No. Compartments f 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 Foundation Property Line ct. t `J\ SEEPAGE PITS I I Depth Size r. y SUMPS Number ❑ Distance to riearast: Well DISPOSAL PONDS ❑ Foundation . Property Line S 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 followin - em to an g: "'I certify that in the performance of the work for which this permit is issued, I shall not ploy y person in such manner as to become subject to workman's compensation laws of California-" Contractor's(tiring or sub-contracting signature certifies t owing: "I certify tha rformance of the work for which this permit is issued, I shall employ tion sof Ca fornia." p p y persons subject to workman's compensa e applican ust call for I req (rad ' ctions. mplate drawing on reverse side, Signe Title: Date: OR DEPARTMENT USE ONLY Application Accepted by g 9 Oa - te r' �1 i Area Pit or Grout Inspection by Date Final Inspection b Datt�R Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 t d 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 FEE AMOUNT DUE AMOUNT REMITTED CK �• INFO CASH RECEIVED BY DATE PERMIT No, +.EH 13-24(REV,rix 51pf� '/� EH 11-26 [� s