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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Loc.1 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 well/pump and the Ryles and Regulations of the San Joaquin Local Health District. 9 N Q A-- /VeE City / tot Size / PM Job Address la T� c-- e4 •-�-t li e F� Address ••�• �� Phone Owner's Name �] 11� ^-a Contractor qJhfddress a icense No.�,�-Phone r'll TYPE`OF VIlELt/PUMP:"'^ �`�" NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATIQV ❑ SYSTEM REPAIR 11OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .01- DISPOSAL FLD.47 _ PROP. LINE r �_ -" -FbU-NDATi0N _ SRF-WELL 7-�OTHER WELL PITSTSUMPS 0t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION !t Dia. of Well Casin ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation g ??Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type Specifications /2j4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by rr� { Repair Work DAe-0 Type of•Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiclable system m permitted if public sewer is avaInstallation will serve: Residence Commercial Other Number of living units: Number of bedrooms { l Character of soil to a depth of 3 feet: 1 Water table depth f SEPTICTANK _ "Capacity No. Compartments PKG. TREATMENT PLT. ❑ P % Method of Disposal -- Distance to nearest: x Well Foundation, Property Line y k LEACHING LINE ❑ •-No.-&Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation- Property Line SEEPAGE PITS El Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ^` 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws�aW 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 person 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 Califor ia." - The applicant m I red in ecti mpiete drawing on Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by DateArea ", Pit or�o t Inspection by� Date Final Inspection by �i Date ! 6� Additional Comments: ❑ Stk 4664781 ❑ 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 FEE EAMOUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO, INFO + EH 13-24 1REV.1 851 EH 1426 I