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APPLICATION FOR PERMIT 1' ' 5 SAN .!!OAQUI N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1R.�YEAFROM DATE ISSUED T #' (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 describled. This application is made in compliance with,San Joaquin County-ordinance No.549 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.,. 0314.>ifs' .lffrr�. _ I.. Job Ad( ressa City Ae Lot Size_ - :. PM Owner's Name - Te a . - ss Phone Z Contractor's Name se Na. TYPE OF WELL/PUMP: Phone it NEW WELL ❑ WELL REP AGEMENT ❑ DESTRUCTION ❑ " PUMP-INSTALLATION ❑ r SYSTEM REPAIR Q l OTHER ❑ ;I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. " PROP. LINE, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` Q Industrial . ❑ open Bottpom Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well C{sing I ❑ Public a Type of Casing Specifications El Other L7 Delta Depth of Grout Seal ❑ Irrigation + ---Approx. Depth Q Easterri Type of Grout!, Surface Seal Installed by i �! RepaON ir Work Done ❑ Type of Pump H pO Well Destruction Cl Well.Diameter State Work Done Sealing Material (top ') I Depth i Filler Material (Bela ') ► �" TYPE OF S ,EPTIC WORK: NEW INSTALLA N ❑ EPAIR/ADDITION ur DESTRUCTION ❑ (No septic'system permitted if publicsewer.is Installation will serve: Residence Commercial Other' s YW� available within 2D0 feet.)'-- FWD i Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet:' ' I t SEPTIC TANKWater table depth i', ❑ Type/Mfg f "' 1 Capacity : No. Compartments PKG. TREATMENT PLT. ❑ r t f Method of Disposal' i- `Distance to nearest: Well" F�dation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ; Q `%Distance to nearest:` Well Foundation'" r Property Line SEEPAGE PITS L�De th ° r L P � Size SUMPS r v -❑ Distance to nearest:""`--Well Foundation Property Line +i DISPOSAL PONDS 'Q A '1 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: t ' ' 1 - i employ an "i certify that in the performance of the work'for which this permit is issued, !shall not P Y Y person in such manner as to become subject to workman's compensation laws of California."Cohiractors hiring ar srmit I issued, signature�.. certifies the following:"I certify that in the performance of the work for which this ermit is issued,I shall ern to tion laws of California," 1 # P y ip y persons subject to workman's compensa -Thea lican �" '� PP or req r nspections. Com a drawing on ev de.""yr Signed r .. Title: �- .l �-�--'�, . _ Date' li 1 FOR DEPARTMENT USE ONLY � !I Application Accepted by Y Data a ' Pit or Grout Inspection by Date Final inspection by 6 . " Date "Additional Comments: ? §r ❑"Stk -466-6781- t, ❑ Lodi"..,369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant,- Reiurn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE '. AMOUNT REMITTED CK RECEIVED BY I CASH DATE' PERMIr` O. r EH 13-24(REV 101 'E631 H 1426... ... O n M