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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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.5491or sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address Cit Lot Size PM I " SA Owner's Name Address 135-0 q� _ Phone Ca- Contract o Address Cltense No. �6 Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industria! ❑ Open Bottom ❑ Manteca _�"`Oia. of Well Excavation Dia. of Well Casing V-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f7 Other C1 Delta Depth of Grout Seal Type of Grout-.._ I I Irrigation Approx, Depth I 1 Eastern Surface Seal Installed by _ Repair Work Dane (Type of Pump 14-41-- H,P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION i I DESTRUCTION I 1 INo. septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other I Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Mefhod of Disposal - ``� Distance to nearest:!, Well' ' Foundation Property Lined 1 LEACHING LINE ❑ No. & Length of lines Total length/size - I FILTER BED ❑ Distance to nearest: Well Foundation Property Line 2_0 1989 t SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property LinePE I 'N�f� HEALTH DISPOSAL PONDS RMITISRVICPo El 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 DiMrict. 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." 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." The applicant must or all require inspections. Complete drawing on reverse side. Signed X.._� 005 Title: Date: FO DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by # bate Fina! Inspection by Date�� Additional Comments: 0 Stk 466-6781 D 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 1324 IREV.I/ EH 14-28 ;