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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AfVE., 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.549 for sewage'or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3 City of Size PM ' Owner's Name Address f� hone Q 0 i I Contractor's Name S License No. �� .M5 Phone TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTIR ❑ DISTANCE TO NEAREST: SEPTIC TANK A00' SEWER LINES DISPOSAL FLDA0 �" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 50 / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -(Man ca Dia. of Well Excavation OY Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Typeof Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 901 Type V Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 'r State Work Done Vzhc,+iVe"� tructi n ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') I TYPE Or SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION;❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial— Other II , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '1 Water table depth SEPTIC TANK ❑ Type/Mfg II Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines IM Total length/size FILTER BED ❑ distance to nearest: Well Foundation Property Line il SEEPAGE PITS ❑ Depth Size IM Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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. l 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 California." .appli nt ust call for all requir d pections. Comp) a drawing on reyesid Signed tle: V.S. ? Date: a2— I{ ' F DEPARTMENT USE LY Application Accepted by Date S ZZ Area Pit or Grout Inspection by �,,��Q�Y`6ate �' Final Inspection by jv Dat 1 Additional Comments: �� " '►�-� 1n 51+�1 r 4 � + ElStk 466-6781 El Lodi 369-3621 JKManteca 823 04 E3 Tracy 835-6385 s Q o4? • Applicant- Return all copies to: Environmental a Ith Permit/Services 160' E. Hazelton Ave., P.O. Box 2009, Stk., CA a5201 FEE { INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13426241REV.f0la3! � �3 EH 11.1,4