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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA �/��j V� LD PA"m L A Telephone (209) 466-6781 /!ernC ✓1 J MA IA q�03 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C '{ _r/ �,,.4 4�--4I (Complete in Triplicate) �f'�` ` ' fill, (�6�T ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the a licatio s Q... d in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the F les 'd aftwan,i.P I Health District. cro b Address �� • OZ City Lot Size PM O er's Name , Address Phon Contracts; ddress License No. Pho. 6 TYPE OF WELL/PUMP: NEW WELL�Z WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOW❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C12I_ ll^��--") ❑ Industrial ❑ Open Bottom EDManteca Dia. of Well Excavation - Dia. of Well Casing -r"�1 ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ — Specifications ❑ Public .❑ Other ;VDelta S}trkta�. Depth of Grout Seal _ a 3o' Type of Grout El1 ! ' Irrigation d!SD�Approx. Depth ❑ Eastern Surface Seal Installed by_ - I Repair Work Done ❑ Type of Pump 5M. a t H.P. __ State Work Done Well Destrr{ction ❑ Well Diameter %\-CSealing Material (top 50'1 QeA♦g.C,.+ - y Moh; (}x, Depth Filler Material (Below 50') _ d TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION F DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other 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. ❑ Method of Disposal Distance to nearest: Well ___ Foundation _ _.__ Property Line V LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ __ Property Liner SEEPAGE PITS F1 Depth Size ___ - _- -__- -_- Number SUMPS Distance to nearest: Well __ Foundation __ Property Line DISPOSAL PONDS ❑ 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. L 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 folio ing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- U tion laws of Cali 1 . The applicant or all required inspections. Complete drawing on r ver e side. Signed Title: _ 1"657Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area r � $c�a� Ph or Grout Inspection by �+ Wr l Date mal nspection by Date Additional Comments: ��? ��C/[. ,I/�� oz ❑ Stk 466-6781 ❑ Lodi 369 ❑ Mant 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# RECEIVED BY DATE PERMIT*NON. INFO CAS '^ L� p •+ EH 1324IREV.1ie51 r 3S CRS14 �`�� V" Q EH 14-28 �-�O