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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone 1209! 466-6781 PERMIT EXPIRES 1 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �t Job Address / p''�� '" city ot Size PM Owner's Name leA.). CANfddress Phone r Contractor r Address 1 License No. Phone -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ y DESTRUCTION 0 PUMP INSTALLATION © SYSTEM REPAIR EIOTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ` PRO. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS- } 4 LJ Industrial D Open Bottom ❑'Manteca Dia. of Well Excavationes 'r a Dia. of Welk Casing ❑ Domestic/Private ❑ Gravel Pack �❑ Tracy Type of Casing��. r��-�:' " Specifications' n Public Cj Other ( rl Delta Depth of Grout//S�ea`I - Type of Grout I I Irrigation —..Approxi Depth fl-I Eastern Surface S.6 to lleolby, �, li Repair Work Done ❑ Type of Pump �. H.P. �1I'�---�_ State--Workf�Done Well Destruction ElWell Diameter `; Sealing M tial (top Depth ( Filler Materal (Below TYPE OF SEPTIC WORK: NEW'INSTALtATION 1-1 REPAIRj./>WDDITION I-i DESTRU CTI-ON_l I No septic system permitted if public sewer is A ( available within 200 feet.] Installation will serve: Residence_ Commercial. Other 11 Number of living units: Number of bedrooms \1 + Character of soil to a/depth of 3 feetr 02rf >� Water table depihrs SEPTIC TANK ❑ Type/Mfg10' i `�_/Capacity �No. Compartments' PKG. TREATMENT PLT. ❑ - r ��/ Method of Disposal Distance to nearest: Weil fid. ./Foundation Property Line Z LEACHING LINE ❑ No. & Length of lines w— Notal length/size! ILTE �/ Distance to nearest: Well a -- Foundation /�`�- - Property Line 1_ _ SEEPAGE PITS 1 i I Depth �$iYef 4 Number ' SUMPS r D Distance to nearest: Well Foundation"—7�_____ 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 Di§trict:' 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 compensatioWlaws of-California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance'of the'work for which this perrnit.is issued, I shall employ persons subject to workman's compensa- tion laws ofCalifornia." The applicant m call f all re�u`ired ins ions. Com /alfa wing on rav/elsefrside. J� Signed X �" Title: ` Date: t R DEPARTMENT USE.ONLY Application Accepted by Date . 4 Area Pit orfGrout Inspection by f Dae Final Inspection by Tn4L_ _ Addit{ if ional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl/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 FEE4 ' INFO i AMOUNT DUE10' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. * Ell 3.24 EH 14 26(REV.1/n 5) r`r