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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA { Telephone (209) 466-6781 f PERMIT EXPIRESI.YEAR FROM DATE ISSUED . ,.• _ (Complete in Triplicate) ��. •`_ 3 r 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 for sewage o 'u.nty Ordinarice o.N 549 r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Co1 Local Health District: { ;y ! Job Address 9 s plop City G Lot Size PM. : �I -�✓�/- 1 ell � Address Phone Owner's Name _ f �-�-p 1 Contractor �- J AtlressF 0 oh11 License No. 7�`�a J Phone Ad TYPE OF_WELLLPUMP:_4NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE NlELL 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 El Gravel Pack ❑ Tracy Type of Casirig r Specifications ❑ Other ❑ Delta ( Depth of Grout Seal ft { Type of Grout ❑ Public x- w 1_ . ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal lnstallediby = C Repair Work Done ❑ Type of Pump H.P. State Work Done WellDestruction 71 Wel1_Diamete'r Sealing MateriaC[top..50y� s Depth Filler-Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTALLATION k/ ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is k; available{within 200 feet.) ` Q� I'n'stallation will serve: Residence�Commerciai Other { Number of living units: __L Number of bedroo tt Character of soil to a depth of 3 feet:,-. T ' Water table depth i" s Ca 'D No i Compartments SEPTIC-TANK ..� °-❑- Type/Mf9 ��u _ � lid pacity�Q_ " 1/f, ' q hod fsal ' ispp 8 PKG. TREATMENT'PLT. ❑ Meii Distance to nearest: Well FEoundpition Property Line {�1 <; } ., ; Total lengthlsize 00 LEACHING LINE (�No. & Length of.hnes.- 5 FILTER BED ❑ Distance to nearest.4 -1 �!u 1t� ~Well F ndation Property Line '- .Ile SEEPAGE PITS- ❑ _ Depth Number i. SUMPS: 171 Distance to nearest: Well'" IF Property Lme DISPOSAL PONDS ❑ � I herby certify that I have prepared this application and that the work will'.be done i a cordance with San Joaquin county ordinances, state laws, and 3 rules and regulations of the San Joaquin Local Health.District. i 4" 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, l shall not employ any person in such manner as;to become subject to workman's compensation laws of"California."Cont"rector's hiring or sub contracting signature ' r persons subject to workman's compensa t certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall p 1 X tion I,bws of California." {l t The applicant must call f all r uired inspections. Complete drawing on reverse side. Sned Title: i [ t Date: i g E. FOR DEPARTMEN;[USE ONLY E Application Accepted by Date J ? / Area e 7 1 " Final sonspection by t Date Pit or Grout Inspection by Date t# 1 Additional Comments: 3 O Stk 466-6781 ❑ Lodi 369;3621 [1 Manteca 823-7104 ❑Tracy 835 6385 i - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax,2009 Stk., CA 95201- ... FEE AMOUNT DUE, AMOUNT"AEMITT.EO_`__..^CASFI RECEIVED 9Y.r.- DATE - PERMIT-NO: gNFO + EH 13241REV:1/e5l 5 1g _ YEH 14-26 -- - I