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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA Telephone {2091 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. 1862 for welflpump and the Rules and Regulations of the San Joaquin Local Health Distrim Job Address � - ale" City Lot Size PM Owner's N" Address _ Phone Contractsddress 6 License No. J`-� Phone .. _ lz�TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION 13 SYSTEM REPAlR ElOTHER L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLO. PROP. LINE- FOUNDATION AC`iRiCULTUI3E WELL OTHER WELL - i�IT�1SUfilP� INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS Q CI Industrial 15--op. Bottom ❑ Mante Oia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 13 Gravel Pack 0 cy Type of Casing Specifications V l'I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I irrigation Appr epth I I Eastern Surface Seal Installed by - Repair Work Doric ❑ Typt Pump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material Itop 50'1 Depth _ Filler Material IBeiow 50'1 _ - -- TYPE 6F 5 C WORK: NEW INSTALLATION H REPAIR/ADDIIEON : I DESTRUCTION t 1 (No septic system permitted if public sewer is available within 200 feet.) Installation wiil serve. Residence-A Commercial— Other Number of living units: _-I-- Number of 11frooms f Character of soif to a depth of 3 feet: Water table depth SEPTIC TANK IrType1Mfg Capacity,F/� No. Compartments PKG. TREATMENT PLT.D Method of Disposal { / Distance to nearest: Well -- Foundation s-- Property Line LEACHING LINE + OK No. 8 Length of lines r Total lengthlsize x� f FILTER BED LJ Distance to nearest: Well 6;h � foundation�D Property.Line SEEPAGE PITS ; I Depth __,Size Number SUMPS -C'. Distance to nearest- Well Foundation_�,-.__ Property Line _ DISPOSAL PONDS r7 l hereby certify that I have prepared this application and Thai the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local health Diltrict. 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 compensations laws Of Calitornia-"Contractor's hiring or sub-contracting signature certifies the foI[awing:"I Certify that in the port ormance of the work for which this permit is issued,I shall am ploy porsans subjact to workman's compensa tion laws of California." The applicant mus ail for all ragttirad inspections. Complete drawing on reverse side. Signed x__ ^ Title: ! . Date: FOR DEPARTMENT USE ONLY Application Accaptad by Date `� rl♦r � Area Pit or Grout Inspection by Date Final Inspection by r _ Date Additional Comments: �•' '�?' �M71�04 C' Stk 466-6781 ❑ Lodi 369 3&21 ❑ MantecaL acy 83 5�i385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk„ CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 8Y DATE PERMIT NO. INFO CASH rte p ,.EK13.24MEV t+Nbi r�-{ r�- 1 EK 1a•2e