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• � �U� l c� U _�A:�,ti APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) k E 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 or No. 7$6?for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage Local Health District, Job Address City A'4/+fa0 Lot Size ( a PM i� Owner's Name Lv Address Phone 3a� Contractor e � '-�� Address �Y OC f5 License No. 3; 7� Phone_ TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, - _SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � Specifications a F] Public F1Other L] Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by Ij Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION frl REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i i available within 200 feet.) Installation will serve: Residence z/ Commercial_ Other Number of living units: 'Number of bedrooms Character of soil to a depth1.'of 3 feet: ZDA M Water table depth �� r SEPTIC TANK R"'Type/Mfg rom Capacity >'(P0C) No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal r Distance to nearest: Well SO Foundation Property.Line, �(t ` LEACHING LINE rfL�y No. & Length of lines 0' Total length/size �� l l FILTER BED ❑ i'Distance to nearest: Well -� Foundation c�5 Property Line - SEEPAGE PITS IUi Depth } Size 3 Number�Q Property Line 2�, i SUMPS Ll Distance to nearest: Well. Foundation l �_, ' DISPOSAL PONDS ❑ r 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. Homeowner or licensed agent's signature certifies the following: "I certify that in the periormance•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." Contractors hiring or sub-contracting signature certifies the following: 1 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 must call for al required inspections. Complete drawing on reverse side. 1� Signed X Title: Date: �� �f FOR DEPARTMENT USE ONLY E Application Accepted by Date d Area p L �a Ins it or Grout Inspection by ate Final Inspection by `DaEE ` I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T cy 835-6385 =, Applicant- Return all copies.to: Environmental Health Permit/Services 1601_E. Hazelton-Ave., P.O. Box.2009,-Stk., CA ( FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. CASH INFO • ' I +.EH 13-24(REV.?/B! 5) EH 14-28 .i�,;