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IPS. APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT i 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 Local Health District for a permit to construct and/or install the'work herein described. This application is made in compliance with San OJ�+u�C�i�rdinancetyo.549 f�1 sewage of No.1 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. pt '`T Wk t-- L- !,C",�C ivi 71,. 1 f Job Address R Vk City N Lot Size PM Owner's Name ��L� arrr ZL Address ( Z Phone Contractor Address 3 License Noe,2 9-6ft Phone -3 TYPE OF WELL/PUMP: AIEW WELL WELL REPLACEMENTW DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _.� SEWER LINES RS' t DISPOSAL FLD. PROP. LINE �e FOUNDATION AGRICULTURE WELL OTHER WELL AC_ ! PITS/SUMPS /yam INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca _ Dia. of-Well Excavation 1a7 �i Dia. of Well Casing Domestic/PrivateGravel Pack El Tracy Type of Casing�f9E/L' __ Specifications 1-14,47LJ Public ❑ Other ❑ Delta Depth of Grout Seal SD o!!J rW Type of Grout r ❑ Irrigation _Appr6x. Depth ❑ Easternurface Seal Installed by Repair Work Done ❑ Type of Pump S4.A H.P. ..,_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other f F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth Z SEPTIC TANK ❑ Type/Mfg ~� Capacity ; No:Compartments PKG. TREATMENT PLT. ❑ ' ,� Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines - � � �'�"�'7otal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C7 Depth Size Number r 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance-&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 California." The applicant must call f all required inspec ions. Complete drawing on reverse side. ; Signed (�,�J Title: Date: �O FOR DEPARTMENT USE ONLY V, Application Accepted by Date"� 1 95 Area � Pit or Grout Inspection by Date ( - Final Inspection by Date! Z Additionaj Comments: — � `` b `IX tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 b Tracy 635- Ap nt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO IREV.t/asl EH 11426 ',�� 7 X70 • - l 1 -A S 77