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APPLICATION-FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON"AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FRO.M,DATE ISSUED : , t T �.t 7 "(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. *. „>>c/i11: Job Address fV"' City — Lot Size cit fl PM Owner's Name�f - �• Address - - - Phone � � Contractor's Name License No. 45"Zil Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _x 'SYSTEM"REPAIR-0-4i_ -� (`OTHER`❑" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROKLINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ` w ❑ Open Bottom,! —.❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private A Gravel Pack tLlTracy Type of Casing Specifications ❑ Public ❑ Other i El Delta Depth of Grout Seal Type of Grout A Irrigation `)Approx. Depth ❑ Eastern Su ce Seal Installed by ! Repair Work Done ❑ Type of Pump �,�_.� �/ H.P. State Work Done _ Well Destruction LL ❑ "Well Diameter Sealing Material {top 50') S Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is r ` _ �'_ -■ available within 200 feet.I Installation will serve: Residence—_ Commercial_ Other c Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TYPe/-Mfg. - - Capacity No. Compartments A� PKG. TREATMENT PLT. ❑ f ,, 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 -SEEPAGE PITS ❑ -Depth <"Size Number -- - - SUMPS ❑ 'Distance to'nearest: "Well" Foundation Property Line DISPOSAL PONDS - ❑ * i 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 1 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 cal for a I required ins ctions. Complete drawing on reverse side. ? + s Signed -- Title: / r FOR DEPARTMENT.U69 ONLY Application Accepted by Date �A$ea Pit or Grout Inspection by I y Date Final Inspection by t z A itional Comments: A Stk 466-6761 ❑ Lodi 369-3621 EI Manteca -8x3-7104; ❑ 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 CASH RECEIVED BIT Y DATE PERM "NO. I+r' INFO +EH 1344(REV,10183) l EH 1426