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.; APPLICATION FOR PERMIT K SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the an 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 Nq.549 for se age or No. 862 for well/pump and the Rules and Regulations of the San Joaquin. Local Health District. /VAt/�l/ C5b`n '�/9 Job Address ' City Lot Size PM ff Owner's Name _770� �ess Phone Contractor TrU-- __Address _ ALicense No.5_/944!6Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C)l �1rr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS __ aLX W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOP,S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ -7 Dia. of Well Casing�rl ❑ Domestic/Private a Graver Pack ❑ Tracy Type of Casing Specifications (`1 Public ❑ Other ❑ Delta Depth of Grout Seal '` �© Type of Grout.' I I Irrigation .-.-Approx. Depth ( 1 Eastern Surface Seal Installed by ( r� Repair Work Done ❑ Type of Pump H,P. State Work Done— �V Well Destruction ❑ Well Diameter Sealing Material (top 501 t ,Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di1trict. Home owner dr 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-conlracting signature certifies the following: " ertify 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 Califor The applicant mu II for allre it dinspections. Complete drawing on reve ide. Signed X Title: Date: ORD ARTMENT USE ONLY g f Application Accepted by Date / Area f Pit or Grout Inspection by Date Final Inspection by Q Date 6 Additional Comments: - Q ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 M Tra 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. s�.,. euo, c +.EH 13-24(REV.i/At) _r 3/9 p ctp_S�[_cl EH 1428 / 1 1