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APPLICATION -FOR PERMIT 1984 SAN JOAQ,UIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA SAN jOAQU114 LOM I Telephone (209) 466-6781 DISTRICTPERMIT 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 forssewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. Job Address -J( �,�V t"G(C:{ L(� City Lot Size PM Owner's Name 11 Address �3�. )6A,& Contractor's Name .License No. Phone TYPE OF WELL/PUMP:. VNEW WELL . WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK "__Jct_= SEWER LINES i DISPOSAL FLD. PROP. LINE JCL FOUNOATEON" AGRICULTC)RE"`WE>_L OT.HER"WELL PITS7SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private Gravel Pack J""racy Type of Casing .0ye� Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal (!z Typg of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 1 H.P. State Work Done --�J Well Destruction ❑ Well Diameter A Sealing Material (top 601 , Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ^r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 .4 SEEPAGE PITS ❑ Depth I Size Number SUMPS _ 7-1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ e _, I hereby certify that l 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. i -i 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 of Cal'ornia." f f The app iic nt ust call for all required c pections. Co late drawing on r verse d . Signed Title: Date: OR DEPARTMENT USE ONLY D Application Accepted by - date � 2� � Area 7 � Pit or Grout Inspection by / Final Inspection by let Date I Additional Comments: } ❑ Stk 466-6781 ❑ Lodi 369-3621;..# ❑ Manteca 823-7104 ❑ Tracy 835-6385' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i A FEE INFO AMOUNT DUE AMOUNT REMITTED I CCK-"'I RECEIVED BY DATE PERMIT NO. + EH1324 iREv.101831 EH 1426