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:k I APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 tmade 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 I Local Health District. I� Job Address 70/ AJ City Lot Size PM Owner's Name A 11G Address Phone Contractor Address3J f License No, Phone TYPE OF WELL/PUMP: I NEW WELL 17WELL REPLACEMENT ❑ DESTRUCTION LJ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � - r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il'Public C1 Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation C ,f �1..Approx. Depth { I Eastern � Surface-Seahlns[alled.by = =-��- Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION 1 PAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is it � �-oavailable within 200 feet.) Installation will serve: Reslence �t mmercial_ Other ' Number of living units: Number of�edrooms� Character of soil to a depth'of 33 feet: .t Water table depth SEPTIC TANK 1^i�fype/Mfg ! Capacity--/ M No. Compartments PK TREATMENT PLT. ❑ �� � _�-- � Method of Disposal Distance to nearest: well 'Founn-daTidn'�""`""Property LEACHING LINE ❑ No. & Length of lines -7 Total length/size FILTER BED LL—Distance to ne`re�stf /Well Foundation ., Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property/Line DISPOSAL PONDS ❑ �1 I hereby certify that I have prepared this application and that'the work.will'be done in accordance with(San J6aquin�county ordinances, state.laws, and rules and regulations of the San Joaquin Local Health District. (` 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fpr 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 subcontracting signature I certifies the following:"I certify that in the performance of the work for which this permitis issued, I shall employ persons subject to workman's compensa- tion of Calif.rn1 II 1 The applicant t call fo II re ired 1 s ion om a drawing on reverse _si e. Sig } Title: �* Date: FOR DEPARTMENT, USE ONLY i Application Accepted by 1lwlDate = Area Pit or Grout Inspection by II. _ Date Fina sp cti/o�n,by' att l/1/6 I Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Y i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rEF INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1A EV.1/11 51 7L./9 EH 14-26 ! / l {r