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/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA FJ 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 16 r U r n VC Q E,4,--4 11 � o Q ES 4 L4 1QV L SS PM a , � Z O � � City Lot Size Job Address Owner's Name Address 4Phone -13-L-3--u-1 Contractor- Address S ere, �- �� (Le-License No. 3Ws Phane r�'U TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK p SEWER LINES 1140 + DISPOSAL FLD. PROP. LINE FOUNDATION �* f AGRICULTURE WELL OTHER WELL 20t PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r al to S� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ti f Domestic/Private Gravel Pack ❑ Tracy Type of Casing—_ Specificationsjy .. M Public ❑ Other Ll Delta Depth of Grout Seal Olt) Type of GroutLL=- I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by - 1 Repair Work Done ❑ Type of Pump _'JIVO H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') � Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is V available within 200 feet.) t 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 7 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line t� �1 SEEPAGE PITS 11 Depth Size Number r { SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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 persons subject to workman's compensa- tion laws of Galifo The applicant/m�r call for all required ins pe tions. Complete ing on reverse side. Signed X Title: C Date: t { DR DEPARTME T USE ONLY Q Cl- 019 Application Accepted by / Date Area p FiPit or Grout Inspection by Date ? inal Inspection b DatAdditional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: EnviroFpmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT No. INFO CASH 3 I + EH 13-24(REV.i/N 5)W AJ 3 1 t� �; � -�2 1-- 2-7 EH 14-26 Q