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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th wnsn:d scribed. This app kation 1 made in compliance with San Joaquin County Ordinance No.54�f sewa or Na�r well/ ump d Rmations of the San Joaquin Ff Local Health District, Job Address City Lot Size PM �/ :� vi/WLo�Y� 4 r Owner's Name � � ,Address � � ` Phone 24 `s 2 Fo v -Contractor t dress r /� PLS"' l _ License No./�Phone TYPE OF WELL/PUMP: NEW WELL ❑ ` . WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 i t i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `.� DISPOSAL FLD. PROP. LINE i __FOUNbATi0t _ AGRICULTI,JRE WELL OTHER WELL_.. PITS/SUMPS _ INTENDED USt TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y_ ❑ Industrial f) Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 1 J ❑ Domestic/Private 1 ❑ Pack ❑ Tracy - - Type of Casing Specifications t 7. Public Cl Other Delta o Grout Seal Type of Grouts _ fi�l'i lrrittation I __Approx Depth H Surface Seal Installed by Repair Work pone ❑f .P.Type of Pump T Ht t State Work pone � 1 Well Destruction ❑ t, Wel eter "'Sealing Material Itop 50 / Depth Filler Material Melow 50')� T I f t TY_ PE OF SEPTIC WORK:---NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION MINo septic system permitted if public sewer is t j t t available within 200 feet.) I Installation will serve: iResidence_ Commercial_ Other t .-.Number of living units: Number of bedrooms Character of soil to a depthfeee — el __ Water table depth t t I SEPTIC TANK ❑ Type/MfgCapaci No. Compartments• 'f f PKG. TREATMENT PLT. ❑ r Method i Disposal Q 2 . -"-Distance to nearest:—-Well-'- •— '` Foundation,. Property Line LEACHING LINE '❑ No. & Length of Ii Total length/size _ (_FILTER BED 10 Distance to near t: tion Property Line ._SEEPAGE PITSf I I Depth Size Number ' ' I SUMPS Ll Distance to nearest: Well L�r� Foundat on11U Property Line .DISPOSAL PONDS 0 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 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 y certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's eompensa- - tion-laws of California." _ t t The applicant ust call for al required i pections. Complete drawing on reverse side.- EZ Y .. + hJvti i Signed Title: _ Date: r s F DEPARTMENT USEJONLY Application Accepted by 4' w_� y�,,,��_. - _ Date m�, /_A�oe Pit or Grout Inspection Data Final Inspection by b - V"c�,l<-.�-C.C^ Date a Pk 1 Additional Comment ❑ Stk 466.6781 r' ❑.Lodi'369-3621 - ❑ Manteca 823-71M- ❑ Tracy 835-8385 t`., y�t Applicant- Return al!copies to: Environmental Health Permit/Services 1601 E'Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 FEEMOUNT DUE; AMOUNT REMITTED CK 4 IV t RECEED BY _ DATE _ PERMIT NO. l+e iii INFO - ..CASH': t, _ _ ,..f...EH 13-24—- 1 i A 53 _ '-