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/ � F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM 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 described. This application is i made in compliance with ScID J aquin County Qrcina No.549 for se ag vr; . 1 fowe�puyrsp and a Rules and Regulations of the San Joaquin Local Health District. 1.�'T'�-FG �/.( "a ! _ Job Address .l._ �,. k ryry City Lot Size PM �^ Address Owner's Name Phone Contractor dr ss . License No. Phone l 22 TYPE OF WELL/PUMP: NE1N`W,ELL ❑` WELL'REPLACEMENT ElDESTRUCTION:❑ PUMP INSTALLATION ❑ \,4 SYSTEM REPAIR ❑TANK SEWER LINES DISPOSAL FLDt.-OTHERkPROP. LINE DISTANCE TO NEAREST.,SEPTIC �, ! DIST ... 'I, FOUNDATION AGRICULTURE WELL OTHER WI LL, 'PIT_ S/SUMPS a t. INTENDED USE TYPE OF WELL PROBAM AREA CONSTRUCTION SPECIFICATIONS v Open Bottom ❑ Manteca Dia. of Well Excavation '�nia.lf Well Casing ❑ Domestic/trial ❑ Ope _ � —.... �.-.. r ❑ Indu _ --� j Private ❑,Gravel Pack E Tracy Type of Casing Specifications❑ Public ❑ Other C] Delta 4 _Depth of Grout Seal Type of,�Grout 1 1 � f ❑ Irrigation �4ppro Depth- ❑"Eastern Surface Seal Installed by _ , 1 State Work Done Repair Work Done V❑ Type of Pump H.P. l Well Destruction ❑ Well Diameter Sealing Material (top 50') 1� '-'A Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feethl t Installation will serve: Residence� Commercial_ Other �,r,�✓' 9 ~�� Number of living units: Number of bedrooms �� . T. Water table depth t Character of soil to a depth.of 3 feet - l SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ f _ j Distance to nearest:y Well Foundation Property Line ► r Total length/size LEACHING LINE: ❑# No. & Length of lines R t E F r r ER.BED ❑' Distanceto nearest: Well �! foundation —Property Line EEPAGE PITS ❑ Depth Size = u ber SUMPS ❑ Distance to near t:- Well Q Foundation~ Property Line s DISPOSAL PONDS ❑ 1--= A _ � 1' I hereby certif at 1 have prepared this application end that the work will be done in accordance with San Joaquin county'ordiriances, stater{ , and ru rulation` egs of the San Joaquin Local Health`District. r Home owner or licehsed agent's signature certifies the.following: "I certify that in the performance of the work for which this permit is issued, I hall not empty 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 l [ { p tion laws of California." The applic must c a11,;for I regyired inspections. Complete drawing on reverse side. p �j ✓ Title: - tJcJ'-��J�"r` Date: v�+� ►i 5a' Signed , t �"`"� '{{ .� F DEPA @NT USE ONLY , .. _ Date Area A Iication Accepted by t c Date ' ate Final spection by Pit Grout`Inspection'by ! Additional Comments: t'"�"� - ❑ Stk 466=6781 Lodi. 369 3621 ., Ftl Manteca, 823-7104 1F ❑ Tracy 835-6385 S nob i R Applicant - Return all copie to: vironental°Health Permi /services 1601 E. Hazelton Ave., P.O. Box 2 Stk., CA 95201 ] .V1ull1� C . - FEE AMOUNT D AMOUNT REMITTED r H RECEIVED BY DATE ' P IT NO: INFO __ r {+ EH.13-24(REV.t 7 H 5I EH 14-26 - -