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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 C-4AZEL i ON A4, 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 or a permit t0 Construct and/or install thmade compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the e �2d Rules and Regulations of the San Joaquin work herein described. This application is focal Health District.Job Address / � s�TJvif City Lot SizePM�4 Owner's Name py r �f� je�� I Address 6%, ,u � Phone Contracto / �y Addres TYPE OF WELL/PUMP: NEW WELL License No.�'A �[o Phone WELL REPLACEMENT < i.s PUMP INSTALLATION 119-- DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C] OTHER ❑ ,= SEWER LINES DISPOSAL FLD. PROP. LINE — ._AGRICULTURE y�IELL-- �� INTENDED USE TYPE OF WELL P OTHER WELL PITS/SUMPS H_-- — 1 -- _ - _ ROBLEM AREA CONSTRUCTION SPECIFIGATjONS ❑clndustrial —� �._- r ❑ Open Bottom ❑ Manteca ,'�'DomesticlPriva�ie �- '`, D1a.of-,Well Excavation r 'Public [-] Other �'" ❑ Tracy Type�of��asin � ,' Dia. of Well Casing i i7[ ge . Delta Depth of Grout Seal.t SPecificatidns t ` I I irrigation - :T o�t �� --_Approxi Depth 1 I Easfe a ', r aG Repair Work Done L7 " Type of Pum / k urface Seal Installed by Wel Destruction ❑ Q � LrFi.P .e ---� State Work Done Well Well-Di' J Sealing'Material (top-5(') ;i Depth .,.w„ ._.._ _. h° TYPE OF Syj EPTIC WORK: NEW INSTALLATION I:) REPAIrR/ADDITIONller Material ge10 DEc�STAUCTION f '' "•� 1 I (No septic system permitted if public sewer is J! Installation will serve: Residence Commercial available within 200 feet.) -Number.ofJiving..units: Other�� , y Nuirt4erwof edrQom"s•' -_--- �' Character of soll to a depth of 3 feet: "�` "'�'``� •••---- a, SEPTIC TANK ❑ Type/Mfg " Water table depth, E PKG. TREATMENT PLT. ❑ 6pacity-.4^_ No. Compartments Method of Disposal Dista f 1 nce to nearest: t Foundation Well Pr6perty Line ;LEACHING LINE Q Na. & Length of lines FILTER BED © Distance to nearest: well Total length/size .- ;. Foundation T"�. �perty Line SEEPAGE PITS I'I Depth SUMPS Size Number ❑ Distance to nearest: Well DISPOSAL PONDS p Foundation Property Line ! I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rulesrand regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: laws, and "I certify that in the performance of the work for which this permit is issued, I shall not ern<ploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I� certifies the following:: g: "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." t The applic nt mus al all quired inspections. Complete drawing on raver slob`. Signed �. Title: , i Date: t FOR PARTMENT USE ONLY Application Accepted by a' Date O Area i Pirorr�Graut Inspection by L. � ' Date ` Final Inspection by Date t Additional Comments: i K� Q°Stk- 466-6781 O Lodi 369-3621 ❑ M Apanteca 823-7104 �l1 ❑ Tracy 835 6385 plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 � i' FEE AMOUNT DUE AMOUNT REMITTED CK '1 INFO CASH RECEIVED BY PATE I PERMIT'NO. + EH13-24 1REV,t x 51