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f f - I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE.i ON AVE., STOCKTON, CA Telephone (269) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) s I ,' work herein described. This application is Application is•heieby made to the San Joaquin Local Health District far a-permit to construct and/or install the made in compliance with San Joaquin County Ordinance No.549 for sewage ori. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ~ City y Lot Size PM Job Address92 , + Address " ' i Phone I Owner's Name Contractor ddfess License No. Phone - TYPE OF WELL/PUMP: NEWWELL El WELL REPLACEMENT L1 ( DE STRUCT30N ❑ + PUMP INSTALLATION_ ,❑ SYSTEM REPAIR L] #+ OTHER ❑ M DISTANCE TO NEAREST:-,SEPTIC TAN N. SEWER LINES DISPOSAL FLD. _�. PROP. LINE�� FOUNDATION AGRICULTrT OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ON SPECIFICATIONS❑ Oen Bottom ❑ Manteca cavation Dia. of Weil Casing ❑ Industrial p❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Specifications Cl Other ❑ Delta t Seal Type of Grout FI PublicI 1 Ifrigation�-----�--�- Approx. Depth I 1 Eastern nstalled by S r + Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction. ❑ Well Diameter Sealing Material Itop 50') (t . Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:i-NEW INSTALLATION l l REPAIR%ADDITION I 1 DE TRUCTION INo septic system permitted if public sewer is F avail ble within 200 feet.) E 1 r Installation-will,serve:,,,,Residence— Commercial— Other " V a Number of living units: Number of bedrooms77�� t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ s , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line { Number SEEPAGE PITS,, , 4-1` 1.Depth ' Size `..F, �. 5 k i_w SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Y- 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 Di%trict. 41 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 fallowing: ',I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa; l tion laws of California.' t �j r The applicant ust call for requir inspections. Complete drawing on reverse side. ; y i { Signed-X== i :2?: Title: Date: �' OR DE RTMENT USE ONLY ; Dat Area Application Accepted byJ i Pit or Grout Inspection by Data Final Inspection b Date { r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 j FEE AMOUNT DUE:1, AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO -�31' { +.EH 13-21(REV;I./H 5) 3 S - i -EH 14-26 " i