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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p` 1 Telephone (209) 466-6781 INA NO PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VtPL�QX� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ ��I `e itvrik f�erteribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for we11/� iRuJ�srawl Regulations of the San Joaquin Local Health District. y� G Job Address -Y �U� City S7Ver�% Oil_ Lot Size PM Owner's Name Address r" '�G Phone 4' f Contractor ter'�' ` " "'W� Address f License No—Li �s Phone "' TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS — I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT 0 S Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing " 1 Domestic/Private ETGravel Pack ❑ Tracy Type of Casing r Specifications �- aT` 1 I-i Public yl Othetr,; /dItJVY ❑ Delta Depth of Grout Seal l�� _ Type of Grouts I I Irrigation / --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ,f U ATIIII H.P- �Zz, State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 O Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation 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 rI®� 61te laws, and rules and regulations of the San Joaquin Local Health District. �.1 . l��s Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wor �sfL°�ttaI I ttti> 'Qu is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California `f � &>;Of%�Et ,��QQ �wontracting signature certifies the following: "I certify that in performance of the work for which this permit is issue EI'ia�empIciv r' 86 to workman's compensa- tion laws of California." The applicant m st call a uired inspections. Complete drawing on reverVgide. �� Q Signed X Titre: Date: Z--/ ��( {, FOR DEPAR MENT USE ONL Q Application Accepted by Date U Area Pit or Grout Inspection by Date /nFinal Inspection �by` /pDate Additional Comments: /�zC�� yv�Y�J/ � yy, � �7` r/ �B '---�✓ Gr�B� ❑ Stir 466-6781 ❑ Lodi 369-3621 0 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 C RECEIVED BY DATE PERMIT NO. INFO C r-EH 13-24 IREV.i x 5) _ '^' 3 `t7( W[A�SH t a5 EH 14-26 I