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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED y (Complete in Triplicate) Application is he°eby 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.548 for sewage of No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. �f�17 .' City Lot Size PM Job Address C �ss /'J l� A l rePhone k/ I Owner's Name � -...rte-_.....r�. Contractor LO rf c� / Address License No- Phone 3 ' TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION.'❑ SYSTEM REPAIR ❑ i OTHER ❑ DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ---FOUNDATION AGRICULTURE WELD - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL/ PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 ❑ industrial ❑ Open Bottom/ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Otherf Cl Delta Depth of Grout Seal Type of Grout --. -� I i I i Irrigation —..Approx. `Depth i I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pu�trtp H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'i - epth ! I Filler Material IBelow 50') TYPE OF SEPTIC WORK`. NEW INSTALLATION I:1 REPAIR/AQQITION I 1 QESTRUCTION INo septic system permitted i( public sewer is �;'F R�}, vailable within 200 feeLl Installation will serve: Residence Commercial— Other Number of living units: {: N�mber of bedrooms Character._of soil to a depth of 3 feet: W ter table depth I , � ! Y SEPfi TANK ' ❑• Type/Mfg Capacity No.Compartments PKG_: TREATMENT PLT: D } "Methdd of Disposal ,# {.Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & L'edgth,of lines Total length/size FILTER BED El Distance to nearest: Well Foundation �'Property Line SEEPAGE PITS i 11 D p li _ Size _ Number f ° SUMPS i ❑ Distance to nearest: Well Foundation PropertVLirie .a DISPOSAL PONDS'. © J ! I hereby certify that I have prepared this application and that the work will be done in accordan6e 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: "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 followin§: "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 California." The applicant must call.for.all-required-inspections. Complete-drawing..on reverse side. Signed X � �F" Title: _ -Date:- � 0 r f DEPARTMENT USE r0NLY 1 - la�� ' Application Accepted by. .Date ` _I- e�` Area . Pit or Grout Inspection by Date Final lnspection by '`� Data��i. jAdditional Comments: r �� g ElStk 466-6781 El Lodi 369-1621 Elantece 823-7104 ❑ Tracy 835-6385 Applicant- Return all cop!9s to: Envi{onmenta Health Permit/ smites 1601 E. Hazelton Ave., P 0. Box P CIA 01 LDCCt�G l�+�t•L c IT f IFEE NFO MOUNT DUE AMOUNT REMITTED —Ck if CASH RECEIVED BY DATE PERMI7'NO. + T- EH 13-24(REV.° N 5) S �Q� _ , � [�/' EH 14-28