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APPLICATION:FOR PERMIT SAN.JOAQUIN..LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 I made in compliance with San Joaquin County Ordinance No.549 for,sewage or.No. 1862 for well/pump-and the Rules and Regulations of the San Joaquin Local Health District. Job Address �– City 0,Lot Size PM } Owner's Name 1� Address d'F' `� LL 10 Phone _ a R . .,..V � —6 Contractor's Name WC> u-� wRicense No. t Phone, I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout R ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' __ 1 ::��,- C' 11-I.' .. .I.- -C R4 u z IN Well Destruction Well Diameter Sealing Material atop 50'1 Depth Filler Material "Below 501 R '� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/'ADDITION ❑ DESTRUCTION 11 (No septic system permitted if public sewer is. �. available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms „• Character of soil to a depth of 3 feet: r Water table."depth SEPTIC TANK t ❑ Type/Mfg F Capacity No. Compartments ` O PKG. TREATMENT PLT. ❑ �.0: Method of bisposal C� r Distance to nearest: Well a Foundation Property Line 1' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size" i "` ?. Nuinber k SUMPS ❑ Distance to nearest: Well t Foundation ; Property Line - DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with,San Joaquin,cbunty ordinances, state laws;and. rules and regulations of the San Joaquin Local Health District. 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,-1 shaft not employ any pe n in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the.fol ing:"I cert" at in the performance of the work for which this permit is issued, I shall employ persons subjeot to workman's compensa- tion laws ei C k' r..a:"----� �-- - The•applican call for all req ed in s. Co lets drawing on reverse sides 2 r ' "Title: — Date: Y" Signed ' FOR DEPARTMENT USE ONLY /�� i Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: OL Stk 466-6781 E1 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 9 FEE AMOUNT DUE AMOUNT REMITTED CASH :RECEIVED BY DATE" PERMIT"NO. ". INFO 4 IV. r + EH 1324(REV.101831 - / r EH W28 - - . f �