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APPLICATION FOR PERMIT SAN JOAQU€N LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Joaquin County Ordinance No.; fewags o. 1862�or weld/pump and the Rules anuiations of the San Joaquin Local Health District. If 0 �/{l Job Address Ino I u City of Size 20 M Owner's Name Addressal -fll�3 � y- 9J5 Phone x - ,r - TY.� T I S 7Z w Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST_ SEPTIC TANK :SEWER LE ES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICUL U5e WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 it A TYPE OF SEPTIC WORK: NEW INSTATIOPA] REPAIR/�ON I I DES UCTITI,ON l I (No septic system permitted if public sewer is �y available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms_ LV_" Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg +' Capacity fZV L No. Compartments PKG. TREATMENT PLT. ❑ t Method of Dispospl Distance to nearest: Well .... Foundation Property Line a U LEACHING LINE ❑ No'- & Length of lines Z x Total lengthlsize FILTER BED ❑ Distance to nearest: Well Al Foundation 30 Property Line Sd = rl SEEPAGE PITS I 1 Depth 2 Size 3 Number SUMPS 0 Distance to nearest: Well Foundation /0�]— Property Line 0 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, 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 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 parsons subject to workman's compensa- tion laws of California." The applicant/rust call for all required inspections. Complete drawing on reverse side. �, C Signed X Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by Date c Areea� 2 or Grout inspection by r Date Final Inspection by "Date/`/ Additional Comments:' ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 NO, INFO CASH /t + EH 13-24(REV-t/n5) 6r 6 ♦� //0 f- 047 o ~✓�� EH 14-26