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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 f 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 for sewage r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` �C y� � i Job Address O +' •�7 � l✓� '"/ © / .City � Lot Sire PM I — tv � A/ r Owner's Name d V � Address Phone � Contractor//0�/�1 y`d�� Z.� �]��q x Address p r7 �� i 1 License No.gf 34 PhJR :V y WPI TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Jf AldA.,��an yy4L4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE 6 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well £xcavatit� 4 1 �� Dia. of Well Casingoo ❑ Domestic/ rivat LxGravel Pack Cl Tracy Type of Casing PR I �[ Specifications C 1 Public (7 Other [ Delta Depth of Grout Seal / 6Grout-664- ii Type of _ I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter h P..9 �� Sealing Materia! flop 50'I �j�,A-IDc�fr�i �J � V I Depth_Y`Aa tdb L 115�� Filler Material !Below 50'1 n TYPE OF SEPTIC-WORK; NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted it 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: Water table depth /. SEPTIC TANK ❑ Type/Mfg Capacit Y 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 SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I 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. : "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all required 1 tons. Complete drawing on reverse side.. Signed X 2 f�'7 Title: � � Date: /! T FOR DEPARTME T USE ONLY. M Application Accepted by Date p I ` � A Area Pit or Grout Inspection by Date Final Inspection by Date 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. Box2009, Stk., CA 95201 _ FEE AMOUNT REMITTED INFO AMOUNT DUE CK RECEIVED BY r' DATE PERM17'NO. r EH 1324(REV.i i e sl EH 14-213