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APPLICATION FOR PERMIT i w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA fil A,/ � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N (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 Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j� I Job Address�c�"�/ Q City Lot Size PM 11 r Owner's Name �1 G Address/ Phon — L Contractor L ddress License No.�12�23 Phort 1 TYPE OF WELL/PUMP: NEW WELL Ll. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ___ "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL"FLD. PROP. LINE FOUNDATION.I AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom L) Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 I Irrigation _Approx. Depth 11 Eastern S riace Seal Installed.by Repair Work Done 0. Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 3 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (.I REPAIR,44DDITION l 1 DESTRUCTION l I INo septic system permitted if public sewer is V' available within 200 feet.] w(� Installation will serve: Residence Commercial_ Other V' t r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth G SEPTIC TANK ❑ Type/Mfg �_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Prooerty.Line LEACHING LINE 0 .No. & Length of lines Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line n� X Y' f SEEPAGE PITS I I Depth Size — Number r SUMPS Ll '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. 0 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 5 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 California." The applicant t I for alt r fired inspections. Complete drawingreverse side. s Signed X Title: Date: FOR DEPARTMENT USE ONLY r Application Accepted by ' Date ` U Area Pit or Grout Inspection f, Date Final Inspection by Date�_�/s r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 E] 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 CASH RECEIVED BY DATE PERMIT"NO. INFO �} �C r.EH 13"24 TREY.I/n sl EH 14-20