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a APPLICATION /FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone {209} 466-6781 ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San JoagIum 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. 00 Job Address IkF City Lot Size PM Owner's Name ��0.a oS, — Address rV Phone Q Contractor's Name License No. G Phone T OF WELL PUMP; NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR PTIC TANKS SEWER LINES DISPOSAL FLP. PROP. LINE FO i AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy Type ing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout a Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by v� Repair Work Done ❑ Type of Pump`'I H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth r Filler Material (Bel 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX. DESTRUCTION ❑ iNo septic system permitted if public sewer is y available within 200 feet.l Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms 3 / Character of soil to a depth of 3 feet:��AAc4 1_0,4 Water table depth r SEPTIC TANK (Type/MfgCapacity L4MV - No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of linesTotal length/size FILTER BED ❑ Distance to 1 nearest: Well� R-0 Foundation s�0 r Property Line SEEPAGE PITS rfr-Depth 1-2-SSize 6 Number � � . SUMPS C3 Distance to+nearest: Well CI Founda'tion -G t� Property Line/L 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 i certifies the following:"1 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 r i ed ' spections. Complete drawing on reverse side. Signed e: 4Titiod" - Date: FOR PARTMENT SE ONLY ' Application Accepted by � Date ! 15 Area Pit or Grout Inspection by Dates Final Inspection by +c' Date I Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 1324(HEV.101834 �© O �� ` / } �r(Q ,876-1Sd EH W28