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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON,.CA Telephone 12091 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /t Job Address ` ty Cd Lot Size PM Owner's Name 4. / Address Phone Contractor ee " Ao�1e __Address 9X License No. Phor1� Y TYPE OF WELL/PUMP:. ANEW WELL LlWELL REPLACEMENT 11DESTRUCTION F-= PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 6ISTANCE TO NEAREST: SEPTIC TANK, SEWER.LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E) Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing — ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing — Specifications ['1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by A F Repair Work Done ❑ Type of Pump H.P. State Work Done '`Well Destruction ❑ Well Diameter —Sealing Material Itop 501 s... Depth Filler Material IB low 50'1 TYPE OF=SEPTIC_WORK: NEW IN REPAIR/ADDITIO DESTRUCTION INo septic system permitted if public sewec,is available within 200 feet.) Installation will serve: Residence�s C_ommercial Other . Number of living units- ____`-Numberof bedrooms ` Character of soil to a depth oft feet: ; ®An!s� -.-_�Water table depth SEPTIC TANK ' X Type/Mfg Capacity 014 No-Compaitments PKG'TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Iola-- I-oundation Property Line 62"J6!::! LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well"�Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS' LI Distance to nearest: Well Foundation s Property Line DISPOSAL PONDS ❑ -4 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. t 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 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 Califo ia." The apptican call tar require 'ns ons. e-dfaiving on reverse side. Signed X Title: _ _ Date: r. FOR D PARTMENT USE ONLY f Ap lication Accepted by Date J Imo` L—9 7 Area Pit r Grout Inspection by `- Date o -)Final Irts n by Date//r 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 PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE 'PERMIT'NO. INFO CASH r EH 13-24(REV.I/N 5) � g )•_� �s EH M-28 v