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' - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 R.pd!_T EXPIRES 1 YEAR FROM DATE ISSUED P (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. E� t Z Job Address ity Lot Size PM Owner's Name Address �+�– "' Phone — ,f Contractor 4 �`y Address Ze License N0322-OZ-6 Phone 54�: �- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT' ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑f OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" °' DISPOSAL FLD. .�., - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia:'of Well Casing i SC Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public I-1 Other f] Delta Depth of Grout'Seal �+ '( Typ of.,Grout _ I i Irrigation --Approx. Depth ] Eastern S ace Seal Installed by Repair Work Done J, Type of Pump H.P'. Stat ork Dones–_ Well Destruction 91 Well Diameter Sealing Material (top-50') e war •C Depth 14P0 r Filler Material (Below 501 j �-- TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is II T available within 200 feet./ Installation will serve: Residence_ iCommercial_ Other Number of living units: Number of bedrooms d Character of sail to a depth of 3 feet: 'I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal 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 r r SEEPAGE PITS 11 Depth i Size _ Number f SUMPS Ll Distance to nearest: Well Foundation 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. 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 Califo, 'a'' The app� nt mu call for all requir inspectio . Com /eta drawing on side. Ise Signed X Title: �� S Date: lz::� FOR DEPARTMENT USE ONLY Application Accepted by 446 Date 16 1 Area Pit or Grout inspection by Date Final Inspection by Date /tea Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 i ❑ 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 FEE1 INFO AMOUNT DUE i, AMOfU�NT REMITTED CASHRECEIVED BY DATE PERMIT NO. +-EH 1324 1REV.5 i H 51 +� 5 r 1 " ]b �{t'! jvq_j5r5, EH 14-28 �•I L