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S �Y 1 S APPLICATION FOR PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 9 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 Ordinances,""j for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� City Lot Size '/� �j r r PM Owner's Name Address _A_ �j !fid Phone ' Contractor A., r I Address License No.,� _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . � r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Y� El Domestic/Private ED Gravel Pack', ❑ Tracy Type of Casing Specifications M Public f] Other n Delta Depth of Grout Seal Type of Grout I Irrigation �.Approx.,Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION &(REPAIR/AODiTION I•] DESTRUCTION I I .INo.Septic system_permihed if public.sewer.is r» i available within 200 feet.) i Installation will serve: Residence r Commercial_. ther Number of living units: rF_- Number of bedrooms Character of soil to a depth.of 3 feet: AIDa Water table depth SEPTIC TANK ❑ Type/Mfg ,- ASN Capacity G ►t3' No. Compartments t PKG. TREATMENT PLT. El ` �✓ joi Method of Disposal # Distance to nearest: Well Foundation Property Line LEACHING LINE No & Length of lines'' Total length/size 5 /y � .- FILTER BED ❑ Distance to nearest: Well oe F6undcam ation�2r,.ot�r, Property Line�6PrT i SEEPAGE PITS I I Depth } F Size Number SUMPS Cl Distance to nearest: y 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 Diltrict. Home owner or licensed agent's Signature certifies the following: "I certify that in the performance of the work for bvhich.this petmit is issued, I shall not employ,any person in such manner as to 64come'subject to workman's compensation laws of Calif ornia."'Contractor's hiring or sub-contracting signature yy�� 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 aj required inspections. Complete drawing on reverse side. t SignedlXTitle: Date: `�T ' F DEPARTMENT USE ONLY 4 Application Accepted qy bate { Area Pit or Grout Ins' ction b Date Final Ins action by j f �_-.. ..r. � Y - � P y Additional Comments: ❑ Stk` 466-6781 ❑ Lodi 369-3621 ❑ Wriiieca 823-7104 ❑ Tracy 835-6385 pp Applicant -'Retu'rn all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; 8 R FEE _ AMOUN7.DUE. CK i f " INFO . —AMOUNT-REMITTED CASH" ^;—RECEIVED EIy...-,.- DATE — -PERMIT NO-• -•� - r.EH 1324IREV.�/x51 �M �wr d ..a. #., EH 14.28