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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA s 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. " p 4 Job Address City Lot Size P F r ( ; Owner's Name ess F - Phone 4 Contractor ddress L License No. Phone ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 'DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK" 4 SEWER LINES DISPOSAL FLD. PROP, LINE M 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 ❑ Domestic/Private ❑_.Gravel Pack ❑ Tracy Type of Casing Specifications F F1 Public O Other D Delta � ;r A depth of Grout Seal I 1 Irrigation Approx.�. —_ . Depth l I Eastern Surface Seal Installed by Type of Grout rRepair Work Done C7 Type,of Pump H.P. State Work Done Well Destruction ❑ .Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is �� I Installation will serve: Residence �' Commercial_ 'Other available within 200 feet.) Number of living units: �r:Number of drooms Character of soil to a depth-of 3 feet: Q 'SEPTIC TANKC] Type/Mif.g Water table depth Capacity No. Compartments PKG. TREATMENT PLT. C1 `� - Distance to nearest: Well t=-- `- /� Method of Disposal f Foundation tom— Property Line LEACHING LINE ❑ No. & Length of lines "" '� - - • Total length/size FILTER BED s.• LlDistance to nearest: Well Foundation __ Property SEEPAGE PITS I I Depth *- Size + 'SUMPS } 7 -Distance to'neareat: Well Number Foundation Property Line DISPOSAL PONDS 0, t i I hereby certify that I"havere ared$this a (cation"and that the work will be done iri a-'ordane'a with San Joaquin county ordinances, state laws, and P p Pfn� 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 th n,the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California," , The applicant t or 'required i tions. Com et rawing on reverse side- . r� Signed X �aTitle:( C�L a — Date: FOR DEPARTMENT USE ONLY r Application Accepted b Dates Area Pit or Grout Inspectio by. t`)'. Date Final Inspection by Date -2 4 J 4y Additional Cofhments: D Stk 466-6781 ❑ Lodi '369 3621 anteca 823-7104 ❑ Tracy 835-6385 In, h 'Applicant- Return all copies to:.Environmental Permit /Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE CK v INFO �f AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. + EH 13-24(REV.1/n 51 EH 14-26 / s