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,r APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 549 for sewage or No. 1862 for welllpum. and the Rules and ReguI tions of the San Joaquin Local Health District. 1 ° . �X a�iA- Job Address (J7e dr City Lot Siz ekoL PM r Owner's Name Address Phonz 2 ff / Contract IV Address icense N0.134F� Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT`S DESTRUCTION ❑ PUMP INSTALTION SYSTEM REPAIR ❑ OTHER C1DISTANCE TO NEAREST: SEPTIC TANK/;09-- SEWER LINES f.?O DISPOSAL FLD. PROP. LINE 1:5ff FOUNDATION `erd-` AGRICULTURE WELL OTHER WELL-;,PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia.of Wgtasing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout fi_Q�-_C' I I Irrigation _-Approx' Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ` H.P. ` - State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') r ' Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is w available within 200 feet.) Installation will serve: Residence Commercial Other w {' 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. ❑ 'j� . - .!I.Method of Disposal Distance to nearest: Well foundations t 'Property Line LEACHINGLINE CI No. & Length of.tines 'A Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation k 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."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 parsons subject to workman's compensa- tion laws of California." x I The applicant.must call for all required inspections. Complete drawing on reverse side. Signed X Title: `+pt FOR DEPARTMENT USE ONLY Application Accepted by f,,01 Date Ara �► I Pito Grout spection by e. --v / r� Final Inspection by Date ark Additional Comments: ~ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 DUfc AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO h� t.EHi3-24INEv.i/a5r EH 1426 —!