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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x . 1601 E. HAZEL i 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 t 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 E Local Health District. /' f Job Address V `� fir' aJ City AlLot Size PM Address �l1 !�t'? S5-() gka 'S IV Phone �! S' . Owner's Name 1 ItI Contractor&_:�Z 1ii" E/ -� CAddress l C A SC TLicense No. d ??ft 1 . Phone 3&9'3 E" TYPE OF WELL UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A SYSTEM REPAIR ❑ OTHER 11 r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIME - ._ •,� .. --FOUIVDRTiON "'-'FfiGRiCi7tTtiR�-1IUEt`L "r�"�703`tiER'WEt-ti=�1'IT5-f51yMPS,-"-�--� '�—""'; { 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 1'1 Public Cl Other El Delta Depth of Grout Seal Type of Grout r ;IT Irrigation —.Approx. Depth 13 Eastern Surface Seal Installed by - Repair Work Done LI Type of Pump Kk81At H.P. e25 State Work Done ��t7ct��c 7 Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR l 1 DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence_ Commercial_ Other 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 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED - ❑ Distance to nearest: Well Foundation Property Line t-' SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line ` = -_—DISPOSiA1 PONDS`*SLI, "r 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,T rules and regulations of the San Joaquin Local Health District. F 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 r certifies the following: "l 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 applican ust ca or all required inspections. Complete drawing on reverse side. . Signed X - Title: Date: FOR DEPARTMENT USE 64Y Q/ Area r t + ` . Application Accepted by Date If/7/f/ Pit or Grout Inspection by Date Final Inspection _/ , Date Additional Comments: sy ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-A04 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. IF c CASH +.EHt3-244NEV.r/H51 PR• � v EH 14.29 _