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�r - " APPLICATION FOR PERMIT p SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E.HAZELT0N CAVI;:, •STOCKTON, CA f 466-6781 _ U Telephone (209)X PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) •8AN JOAQUIN � .4;7,? P.nwTt ion is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo s�made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and flegulatioifs' oaquin Local Health District. .01 �[ PM f i� u t City. Lot Size Jab Address / 1 �/ Phone f S e � !�/'+19 a6t GpFd4ti�ess J { Owner's Name _. 1' ` 7 Phone Contractor's Name �'� se No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I DESTRUCTION ❑ ]PUMP;INSTALLATION ❑ SYSTEM REPAIR y OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ) SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL s OTHER WELL PITS/SUMPS TENDED USE TYPE OF WELL ' PROBLEM AREA.-;CONSTRICTION SPECIFICATIONS Industrial ❑ Open Bottom •-❑=Manteca ._r -...Dia:of Welh•Excavation= - Dia. of Well Casing " Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack I ❑ Tracy g f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. D pth ❑ Eastern Surface Seal Installed by �LwAI-i.P. State Work Done Repair Work Done ❑ Type'of Pump Well Destruction ❑ Well„Diameter Sealing Material (top 501 IYN Depth I Filler Material (Below 50') k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION d 4No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f!!=-- r Number of living units: Number of bedrooms - -� Character of soil to a depth of.3 feet: �' rWater table depth ty, SEPTIC TANK ❑, T.ype/Mfg > ;. }` Capacity r- No. Compartments S PKG. TREATMENT PLT. ❑ /� s f rte` Method of Disposal Distance to nearest: Well Foundation Property Line` ' Total length/,size LEACHING LINE ❑ No. & Length of lines ; FILTER BED L] Distance to nearest: Well f Foundation Property Line ” t' SEEPAGE PITS ❑ Depth Size Number I SUMPS El Distance to nearest: ' Well Foundation Property Line I 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: "]_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: " rti that int rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californ ." The applicant m f ir�ed'inspecti omplete drawingon revers e. Signed Title: ' ; Date: d FOR DEPARTMENT USE ONLY J,, ! Application Accepted by, v Date Pit or Grout inspection by I v Dae Final Inspection by Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental e h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT`NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +EH 13-24 IREV.10/831 �� EH 1426