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� G APPLICATION,_FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 FILE C PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PY {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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� City Cr Loi Size Z©.�� PM Owner's Name fm ' Address 1129 Sc..��c��k/�-�� r Phone ; ContractorAddress �-D License No.:5 2;k2 Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION JRL PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ❑ Industrial C1 Open Bottom 1-1 Manteca Dia. of Well Excavation 1 09 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing —. Specifications Ll Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r VIrrigation /0l Approx. DepthEastern Surface Seal Installed by Repair Work Done Type of.Pump O' H.P. s' [7 State Work Done v+� 9 Well Destruction 19 Well Diameter Sealing Material (top 50') qv— Depth r Depth �. r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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: H Water table depth !n J SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments 7 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with.San Joaquin cbunry ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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, l shall employ persons subject to workman's compensa- tion laws of California." The ap ' nt mu)call for all reqr Vin.pens. Ga late drawing on p.Merse side: Signed ✓ Title: Date: / L FOR DEPARTMENT USE ONLY Application Accepted by , .r �__ __ Date Area b Pit or Grout Inspection by Date Final Inspection bv Date Additional Comments: 5tk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ID Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV."iR51 V S77— 130 EH 14-28 / b it _