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API me Loc � 1 n APPLICATION FOR PERMIT O p L 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4664781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED. (Complete in Triplicate) Aication 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 le in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin al Health District. P Address +� ner's Name t ltractor's Name �E OF WELL/PUMP: NEIN WELL ❑ PUMP, INSTALLATION ❑ ;TANCE TO NEAREST. SEPTIC TANK FOUNDATION (INTENDED USE ❑ industrial ❑ Domestic/Private ❑ Public ❑ Irrigation Repair Work Done Wel! Destruction 7 ' City Lot Size D PM Address Phone r �se No. PhoneZ216 WELL REPLACEMENT DESTRUCTION i SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLO. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom C3 Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other 0 Delta Depth of Grout Seal �4pprox. Depth El Eastern ` Surface Seal Installed by ❑ Type of Pump H.P. State Work Done _ ❑. Well Diameter Sealing Material (top 5011 Depth Filler Material (Below 501) +.rL yr arr-in, wuriK:! NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r+ available within 200 feet.) Installation will serve: ! Residence — Commercial— Other Number of living units: __1_r Number of rooms t /7'" Character of sort io a depth of 3 feet: Water table depth SEPTIC TANK; 1 ❑ • T /Mf ! + YPe g Capacity.�� _ No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal J f Distance to nearest:. Well x`-40 Foundation if J9— Property Line Ria. of Well Casing Specificationa Type of Grout_ LEACHING LINE l ❑. No. & Length of lines Total lengthlsize� FILTER BED ❑y Distance to nearrest; Well Foundation ZZ 0 _, Property Line Z/T 0 SEEPAGE PITS ❑ 'Depth Size Number SUMPS! r ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I ❑ I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state favus, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agint'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 compenes- don laws of Celffornia." Tho: applicant must all for all reantmel Inspections. Co plate drawing on re rse side. r Signed Title: Data: r FOR DEPARTMENT USE ONLY p Application Accepted by Date Area 8 Pit or Grout Inspection by Data Final Inspection by AV' Date 2 — 9—^1 Additional Comments. ❑ Stk 46&8781 ❑ Lodi 3691621 ❑ Manteca 823-7104 CI Tracy 83548385 Applicant - Return all copies to: Environmental Health Permit/Services 1901 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ]INFO ♦ EH 13-24IREV. 10/831 ip EH 144a AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0. 4Ld I S Y f�