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APPLICATION FOR PERMIT r/ 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) Appt and/of install the work . This cation is madlecntlon is compliance weieby ith made Sanothe)Joaquin County OrdinaJoaquin lHealth nce No.District549 for sewage or permitto 1862 forcwell//pump and the Rules and(Regulations of the San Joaquin Local Health District. (�/� 4 Job Address /[S/ �" �S ' (�I, I !? f]/I l�rcity. r Lot Size PM Owner's Name VA&0/40 ^"y�r�( +AftJ�Addressss o0 �+�•i,� Wn,.� Val Contractor Vy / X `4e/ Address •Q GtD 1 �t+r' NLicense No. Val Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public F1 Other C1 Delta Depth of Grout Seal Type of Grout_ U` I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by - C Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION y4t. DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial X� Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK }X Type/Mfg 1P1 L Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lim LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS kr' Depth X7 Size imp Number SUMPS ❑ 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 laws, and rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agent's signature certifies the following: "I certity 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 fol) Ing: "1 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 Ca rnia." The appli nt st 11 for q ed-inspections. Complete drawing oA&. rse side Signed X Title: //6Date: v FOR DEPARTMENT USE ONLY Application c p d by Date 1t� Area Pit or Grou Inspection ^' �'1Final Inspection by Date Additional Comments: ❑ Stk t - Return 11 Lodi 369ron ❑ Manteca Servic s ❑ TracHazelton 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE A7/j- REMITTED CKW SH RECEIVED BY DATE PERMIT NO. INFO ��/./ 2 � ..EN 1124 IREV.1/"5) / �� EB 1L7s