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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l O 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 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. X _ . d/l , Owner's Name l/ Address�S / Phone Contractor's Name pJ License No.2��2 i� -, Phone TYPE OF WELL/PUMP: NEW WELL u WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM -REPAIR ❑ r, �OIHER ❑ �,,,,�_ K DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom J Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy r Type of Casing Specifications Public ❑ Other ❑ Delta-- —Depth of Grout Seal - Type of Grout Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by— Repair Work Done C Type of Pump H. P. _ _ State Work Done — Well Destruction C Well Diameter Sealing Material (top 50') Depth Filler Material IRelow 501 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 Number of living units: Number of bedrooms Character of soil to a de-pt� h of 3 feet: Water table depth th SEPTIC TANK M Type/Mfg - Capacity �.n�Q� No. Compartments PKG. TREATMENT PLT, C Method of Disposal Distance to .nearest: Wellf_11 Foundation Property Lina LEACHING LINE No. & Length of lines- Total length/size FILTER BED Distance to nearest Well Foundation( Property Line SEEPAGE-PITS—I ,-w -1_/Depth sZJ% -Sze=---�3.� !�_ _ Slumber SUMPS ❑ Distance to nearest: Well ZeCliii Foundation //z-�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. Horne 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 - e 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 c II for ail required inspections. Complete drawing an reverse side. Signed X__ Title: Title: Date: "a FOR DEPARTMENT USE ONLY A') 1/1 1Ti Area Application Accepted by A Date ��_ Grout Inspection by Date Final Inspection by v "` �— Data _� if � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 96201 + EH 13-24 (REV. 10/83 ti EH 14-25 FEE INFOLA DUE AMOUNT REMITTED CK 11 CASH CASH RECEIVED BY DATE PERMIT"NO. 4,. o �- I �%3 V/vA SS%4-13 9 0