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! APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA, rvy Telephone (209) 466-6781 ��+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t� U G (Complete in Triplicate) �� fr` all the work cl3tion is :made in oompliance with Sanade o the Joaqu nnCoumy Ordinauin nce No.549 for sewage permitealth District for a o 1B62 forto cwell/dpump atnd the Rules and IR Regulations of This he San Joaquin Local Health District. r� '] r7 �7 S r� i J '2 L l.-1� v � City 5 6C4< aivLot Size �` '`! / PM Job Address Owner's Name v � AddressL1—PA QV Phone e Contractor L Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ D STRUCTION ❑ PU INSTALLATION 71SYSTEM REPA ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI ANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA NSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ teca Dia. of Weil Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications f'1 Public ❑ Other Cl to Depth of Grout Seat Type of Grout I Irrigation _.-Approx. Depth 1 Eastern rface Seal Installed by— Repair -- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diam r Sealing Material (to 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial — Other J 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 LEACHING LINE ❑ No. & Length of lines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line rb SEEPAGE PITS I 1 Depth Size Number SUMPS Cl 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 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fallowing: "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." ` The applicant must call for all required inspections. Complete drawing on reverse side. SignedTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by4�� Date�_y X�_ r, o Area Pit or Grout Inspectio b Date Final Inspection by �`-�''"-^ Date Additional Comments: �C to -�t �3-a-3 a a a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7404 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO r.EH13-24 IREV.t/K 51 EH 14-26