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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT �F 1601 E. HAZE T ON AVE., STOCKTON, CA t 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 welf/pump and the Rules and Regulations of the San Joaquin P Local Health District. (� T € ( C r ((�� ) � ' I Job Address `� I® lir,.� City-- "► Lot Size fJ� PM Owner's Name g ,Address Phone fW - Contrracto ' s ess c p License No. phone! YW5 S TYPE OF WELL/PUMP: :. NEW VYELL, " WELL REPLACEMENT ❑ DESTRUCTION'❑ UMP INSTALLAX;I.ON C1SYSTEM REPAIR LlOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK—_._, SEWER LINES DISPOSAL FLD. PROP. LINE E ` FOUNDATION; ` AGRICULTURE WELL OTHER .WELL - PITS/SUMPS INTENDED USE TYPE OF WE41, PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open Bottom `: ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pact ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type Of'Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by \� Repair Work Done .❑ Type of Pump H.P. State Work Done V' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth to� •ler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION I1 (No septic system permitted if public sewer is available.within 200 feet.) Installation;Nrill serve: Residencea•�:Commercial— Other Number ofliving units: Number ofjbedrooms 3 Characit rf of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/MfgCapacity I yV No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ bistance to nearest: Well Foundation_1_ _ Property Line_2—CO) LEACHING LINE ❑ No. & Length of lines 2 Total ength/size C FILTER BED ❑ Distance to nearest: Well Foundationroperty Line E SEEPAGE PITS ❑ Depth 2 Size_ -12 A Number SUMPS ❑ Distance to nearest: Well� IA 7A Foundation•"""Z. Property Line y DISPOSAL PONDS ❑ I hereby certify that I have prepared this`application and that the work will be done in accordhnce with San Joaquin county ordinances, state laws, and h 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-cohtracting signature P 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 applicant ust ca11 for.a.1 required inspections. Complete drawing an reverse side. Signed Title:_�+�/"?�/i ._., _ .,_ Date: 2-1 -&2 FOR DEPARTMENT USE ONLY A - ation Accepted by Date ,57r9;7 Area to (Eit Grout Inspection by r/ e� �1 �/ inal Inspection by �QQA& &LAAL L D e77 ' Additional Comments: ❑ Stk 466-6781 ❑ odi 369-3521 ❑ Ma eca 823-7iO4(J ❑ Tracy 835-M //V�// Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA,95201 FEE CK* INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMWNO. If + EH 1 -241REV.ties7 EH 144-28