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I APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. .lob Address J' / � �` '` � City / Lot Size � PM Owner's Name f��" '� Address / ` / 4/4 Phone eo Contractor "- � � / �/A�ress License No 2K � � Phone `/ k TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT D DESTRUCTION PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO?. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS'SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing u Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public F Other F1 Delta Depth of Grout Seal Type of Grout--_ �- I I Irrigation __.Apl}rox. Depth t 1 Eastern Surface Seal Installed by _ I Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction E-1 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 . TY/PE OF—sr= ORK: �WjINSTAIIAsG AIRIA ION I I DEST CTION I 1 INo septic system permitted if public sewer is & /��. 'Y C if available within 200 feet.) Installation will sery Residence_ Ca mere? 'Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments .� PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line ' TEACHING 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 Cl 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 ordinances, state taws, and rules and regulations of the San Joaquin Local Health Di1trict. 1-, 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."Contractors hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m�t It for all required inspections. C mpleta drawing on reverse side. Signe �d X © (_ ,_ =�e J 1 / / r,7'idb-_. 1tiDate: b+ 1 R DEPARTMENT USE ONLY / Application Accepted by net �r` Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466 6781 LI Lodi 369• M nteca 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeltowAve., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. INFO EH 13.21 IREV.iiNSI EH 11-26 / © 8/ 77 p , O c�t E"i ��\ - ��,J 1 —1 H'C.+