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Xz ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ti Job Address City Lot Size M Owner's Nam7_0e��r� ,rz Address Phone ` Contractor Address License No. d6 Phone �O P16 CV TYPE OF WELL'/PUMP: -- NEW-WELL-L-1 WELL-REPLACEMENT-❑ •DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -7- le EJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /a%? Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout w _ I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by - \� Repair Work Done ❑ Type of Pump a H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTION l 1 INo septic system permitted if public sewer is 1� 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 i FILTER BED ❑ Distance to nearest: Well �'foundai!5n Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Properly 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 Di'svict. .t 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 applic t ust call for all require inspections. Complete drawing on reverse side. Signed Title: bate: FOR DEPARTMENT USE ONLY Application Accepted by Date Ji6, Area Pit or Grout Inspection by Date_.�T .. Final Inspection by Q, Date Additional Comments: 2;,nt5tk 466-67$1 ❑ 21 Manteca 823-7104 ❑ Tracy 835-6385 _ Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk. CA 95201 Applicant Return all copies to: Envl o t � r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13-24IREV.t/n51 - ✓ ' � / (MI EH 14-26