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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. AJob Addres City 1. t Size 14-Ai—IPM �.� Address Owner's Nam-9_ - Contract Addresy o License No.32!�22U Phone � "s]�Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` ❑ Public L! Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth 1.1 Eastern:. Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 Depth .,Filler Material (Below'50') TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION l I .DESTRUCTION I 1 (No septic system permitted if public sewer is Y .available within 200 feet.) Installation will serve: Residence_ Commercial__ Other "`• � Number of living units: Numberpf b Brooms y k 1 r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, Cl t . Method of Disposal Distance to nearest: Well s� Foundation Property Line� .� �3 LEACHING LINE fNo: & Length of lines - Total lengthlsize 0 K FILTER BED ❑- Distance to nearest N Well ESQ Foundation_49 Property Line C/ i SEEPAGE PITS 1.1Depth Size ec,7 Number SUMPS Distance to neatest: Well Foundation�/U Property Line �r ` DISPOSAL PONDS ❑�. ' I hereby certifVj iat 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 own6r or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thi§permit is issued, I shall not f " " p y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature em to Ean certifies the following: "!certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- t6n laws of California." The applicant mu 11 for all requir ins ctions. Complete•drawing on reverse side. Signed X - Title: — ,I?h, Date FOR DEPARTMENT USE ONLY f Application Accepted by tom--- Date r X Area Pit or Grout Inspection by Date_ Final Inspection by Date /1 d Additional Comments: C7 Stk 466-6781 Lodi Y369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201FEE {I� INFO AMOUNT DUE AMOUNT REMITTED CLASH RECEIVED'SY DATE PERMIT*NO. r.EH 13-24(REV.I/K5) EH 14-M al