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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIS 1601 E. HAZELTON AVE., STOCKTCI� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE oU5 . •wr w (Complete in Triplicate) 4WI�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and or ww made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/ Local Health District.,, , J (✓,'�g ►OGT I _� V i ri... %I CC -1C I c;_ DRA is 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, 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-e+-Galifornia." The 4plicant m st call for all require ns ctions. Complete drawing on reverse side. Signed X Title: Date: '3 `> FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox . EH 13-24 (REV. 1/ R s. EH 14-26 Area / fl Date FEE INFO &PER IeAsddress F0 6`0X G 1S 5T0C1K_'v q0302. Owner's Name LTAtiA Phone �SIo RECEIVED BY S7ocK-TOIJ 01-97 qT c� Contractor f)Pec:_T" 1 Address 28r --S E. M 2"r� License No. S/Z2�o8' Phone �� 7 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 i� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing z om�esl Dtic�[Pri4Z& SCL4 c) Specifications X, Gravel Pack El Type of Casing FV G 4' I' I Public ��tt �o Cl Other n Delta Depth of Grout Seal 31 —''C7 Type of Grout`^— I I Irrigation __ Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WOR NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ther Residence�ofs Number of living units: NCharacter of soil to a depth of 3 fWater table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 1_1 Distance to nearest: 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 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, 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-e+-Galifornia." The 4plicant m st call for all require ns ctions. Complete drawing on reverse side. Signed X Title: Date: '3 `> FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox . EH 13-24 (REV. 1/ R s. EH 14-26 Area / fl Date FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.