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r - APPLICATION FOR PERMIT \\ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, D r= Telephone 12091 466-6781 4t PERMIT EXPIRES 1 YEAR FROM DATE ,. (Complete in Triplicate) 'JON 2 Q ��Q Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem tfescribed.This application is w made iri compliance with-San Joaquin County Ordinance No.549 for sewage or-No. 1852 for well/0"W� pgnd Regulatians of the San Joaquin Local Health District. y.�..i,. 'ERMITAERV CES TN �n �7 It QL Lot Size PM Job Address �`�' y � '�� City Owner's Name �Q-� ~ `� Address Phone a Contractor ICJ /` U/-lt� Address V v ! St py-" License No. �� 5-1- Phone Z� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �O��T��H,..,,E�I1 ❑ r' DISTANCE TO NEAREST: SEPTIC TANK - — SEWER LINES DISPOSAL FLD.L. �- PROP. LINE �d FOUNDATION AGRICULTURE WELL OTHER WELL PITS_/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing Domestic/Private ravel Pack racy Type of Casing Specification§ ��GJ� ❑ Public ❑ OtPer ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation /440-!Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done :t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth i r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t` available within 200 feet.) Installation will serve: Residence— Commercial_ Other {� Number of living units: Number of be rooms , {I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to of Foundation Property Line LEACHING LINE No. &.Lengt lines Total length/size FILTER BED ! C7 Distaric o nearest: WeII f Fo ation Property Line # SEEPAGE PITS ❑ Dept Ih Size Number SUMPS LJDistance to nearest: Well Foundation Property Line - - -- DISPOSAL PONDS ❑ a -- - - 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, L 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 i Assued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must all re wired ' tions. Complete drawing onre arse side. -- Signed Title: Date: ' F R DEPARTMENT USE ONLYol y Application Accepted by Date r 4 �Area Aoe pP ,. Pit Gro Inspection b y� Date "`Final Inspection by Date 4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ti FEE AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. INFO �-y + EH,13-24Miv-1/851 r `7 -v�-+ g ISS EH 14-28 !