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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEASSUED , 4 :ava ,,3 (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 of No. 1862 for well/pump and the Rules and:Regulations of the San Joaquin Local Health District. ' ' ' 1 .f il, h ; . .. " .{, }. ,. , F Job Address City Lot Size PM Owner's Name �/'�"u '`-'� k k_ ' Address" _5 T - — Phone iContractor Address 422 45!�` (c tC �- License No. �C 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Kindustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Q&Tracy Type of Casing Specifications ! )<Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a ❑ Irrigation --4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .n�a Teel, H.P. State Work Dune -r Well Destruction El Well Diameter Sealing Material itop 50'1 �p __ �e-�� r' Depth 11 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is �� It available within 200 feet.) € lnstallation�wil rve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3e �. Water table depth I SEPTIC TANK ❑ Type/Mfg A` Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance-to nearest: Well Fou_n a Property Line LEACHING LINE ❑ No. & Length of lines" Total length/size FILTER BED ❑ Distance to nearest:- Well Foundation- Property Line' SEEPAGE PITS ❑ Depth r Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS CI i I hereby certify that I have prepared this application-and that work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local Health District:' - s, A ' 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."Contractors 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 California." The applicant muy cal for all requi d inspections. Complete drawing on reverse side. Signe - �� Jitle:.r.9�ms's :�- - �- Date: -A \ FOR DEPAIRTIVIEN1 USE ONLY I C� olApplication Accepted by ��'� " Date 5.�� Area � Pit or Grout inspection by Date Final Inspection by ate r t Additional Comments: _ ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED "CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-241REV.i/y sls�, EH 1428 CCCC......••//// '�P� I