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6-1 n/Q p Jam:!,`- APPLICATION FOR PERM "� v r (�(• V / ppI SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA a' Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) p pS-- / _c�(! Application is hereby made to thelSan Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with S n oaquin County OrdinanS,elNo®�for sewage o�rpNo. 1862 for well/pum and the Rule and Regul ions of the San Joaquin I Locale Health District. ��Y Y1 D . L[/� A? �G( �EC aC� rjePa Z�4,o_� City Lot Size /00, Job Address _ or owner's.Nar `'� �' Address , Pho `-' A\-dl dl Contract, ` Address_ License No,' Phone_ TYPE-OF WELL/PUMP: -NEW WELL "❑ ;e WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑" S, SYSTEM'REPAIR OTHER ❑ ,.DISTANCE TO NEAREST: SEPTIC>TANK'° SEWER LINES "DISPOSALFLD. PROP. LINE FOUNDATION AGRICULTURE W1 LLQ OTHER WELL j PITS/SUMPS ° INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 1 // ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing + Specifications tJd ' ___ _. f'l Public (=l Other � "l l delta Depth�Gr of out Seal --.-.4Type of Grout y Irrigation _._Approx. I Eastern Surface Seal Installed by _ (� IJICA Repair Work Done ❑ Type ,f Purmp H.P.. State Wor Done , t �ll Well Destruction k--o"Well Diameter � Sealing Material (top 50') Depth ` ; Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 %REPAIR/ADDITION I I DESTRUCTION l I (No septic systempermitted if public sewer is available within 200 feet 1 Installation will serve: Residence Commercial __ Other Number of living units: Number of bedrooms Character of soil to a depth of 3"fear— Water-table depth SEPTIC TANK ❑ Type/Mfg Capacity 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 ❑ Distanceito nearest: Well Foundation Property Line _ SEEPAGE PITS I ) Depth I Size, Number SUMPS ❑ Distancerto nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ I 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. 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 shall not II 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, I shall employ persons subject to workman's compensa- tion laws of California." {I The applicant st call or all required,inspections. Complete drawing on reverse side. Signed X� Title: i Date: 2�0 + FOR DEPARTMENT USE ONLY //-� Application Accepted by — Date `' ~' Areay Pit or Grout Inspection by Final Inspection by Datea'�" L 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. Box 2009, Stk', CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY" DATE PERMIT'NO. .t ♦.EH 1324 IREV.t i a 5] - - `y yx r- EH 14-26 S `Q'J �O �I� 8 �t� - -..