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APPLICATION FOR PERMIT obi SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE.T ON 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 permit to construct and/or install the work herein described. This application 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. p 1s Job Address �. City Lot Size. PM y Owner's Name 7" ddress Contractor d ` �- Address TYPE OF WELL/PUMP: NEW WELL — --License No. Phone _ WELL REPLACEMENT ❑ DESTRUCTION 11-iPUMP INSTALLATION ,� DISTANCE TO NEAREST: SEPTIC TANK `� SYSTEM REPAIR ❑ OTHER ❑ - ��-.— SEWER LINES DISPOSAL FLD. FOUNDATION _ 'aF gGRICULTURE WELL 0 ^ PROP. LINE �Q f INTENDED USE OTHER WELL 7 PITS/SUMPS - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industria! ❑ Open Bottom —~ I r� ❑ Manteca Dia. of Well Excavation_�Z ' ,VDomestic/Private Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing_ �, a V` ❑ Public D Other -- Specifications Q Delta Depth of Grout Searf �- ❑ Irrigation ��Approx. Depth TYPe of Grout p ❑ Eastern Su ace Seal Installed by Repair Work DiSne ❑ Type of Pump ! � I Well Destruction Q H.P. State Work Done_ Well Diameter Sealing Material (top 50') �- ' Depth Filler Material Below 50') / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is • F Installation will serve: Residence available within 200 feet.) Commercial_ Other ` Number of living units: Number of6drooms Character of soil to e.,depth-of 3 feet: ' SEPTIC TANK'S, `ype/Mfg t Water table depth PKG. TREATMENT PLT I Capacity_ No. Compartments 4 _Method of Disposal Distance to nearest` I "" Well Foundation" Property p y Line LEACHING LINE' `Q No. & Length of fines '' FILTER BED ❑ Distance to nearest: Well Total length/size i Foundation Property Line l I i SEEPAGE PITS ❑ Depth Size j •Number SUMPS` ❑ Distance to nearest: Well 1 4. DISPOSAL PONDS ❑ Foundation. _' i Property Line 9 + I.hereby certify that 1 have prepared this application and that thetiwork will be done'in ccordan k rules and regulations of the San Joaquin Local-�HealthiDistrict 3` ;. I ce with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "l certify that in the employ anwork l p Y e person in such manner as to become subject to workman's compensation lawsofperformance Contractor'sfor lhir ng or sub-contracting this permit is issued, lsignalturre certifies the following: "I certify that in the performance of the work for which this pe�mit"is issued, I shall employ tion laws of California." p y persons subject to workman's com � '+ bf ' pensd The applicant r V requirections. Complete drawing on reversf side R Signed Title: �. 4 R Date: - �'.F ARTMENT U$E�ONLY } Application Accepted by Date! �3 Area Pit or Grout Inspection by 3 y Date Final[Inspection-by. r� Additional Comments: _. 1 _ _ Date ❑ Stk 468-6781f '•`li�i �� , l �� / I ❑ 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 FEE OUNT DUE' AMOUNT REMITTED CK INFO CA H RECEIVED BY DATE PERMIT'NO. + EH 1V.+iH51 �z n EH - 14284-29 t�,] V