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R M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTL��NT 1601 E. HAZELTON AVE., STOCKTON, CA Vo A,*' �D Telephone (209) 466-6781 Cn PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei is made made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and FM ulati iii �t Local Health District. '�"� "./U,# 0011 _ 1 9 '" 0 .21 Job Address ©� Ir 6�1''D 1 z fl A Cityai A �1�"Size M If Owner's Name �' n e ' QAddress 19 2 Q t" Phone jg Contractor's Name'—� �� a se No. �'� Phone f r 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ � .SYSTEREPAIR ElOTHER 11DISTANCE TO NEAREST: SEPTIC TANK A) C� SEWER LINES ) DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS }, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V F__1 Industrial "Pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 94-56mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `T!.-!Q w i_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ .t.'�A Type of Grout , ❑ Irrigation _--Approx. Depth ❑ Easterner " ' Surface Seal Installed by Repair Work'Zone ❑ Type of Pump_ H.P. _ State Work Done Well Destruction '�❑ .Well Diameter �` Sealing.Material (top 501 Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wi Residence_ ^ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3,fee . Water table depth SEPTIC TANK ❑ Type/Mfg -. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well undatio, Property Line d LEACHING LINE ❑ No. & Length of lines I length/size FILTER BED ❑ Distance to nearest: Well Foundation Line t i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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."Contractors 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 call for all required inspections. Complete drawing on reverse side. Signed X n 0Q. Title: Date: FOR DEPARTMENT USE ONLY p l/ Application Accepted by y c a Date p '�� Area Pit or Grout Inspection by Datel0e"' Final Inspection by Date < 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. +EH 13INFO 24 IREV.101831 C>7 EH W26