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APPLICATION FOR PERMIT qAN JOAQUIN LOCAL HEALTH DISTRICT 'i 1601 E. HAZEL T ON 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 wen/pump and the Rules and Regulations of the San Joaquin Local Health District. �.,. , PM Job Address ' ' 1.�-= City - Lot Size Owner's Name ° �. - l Address - Phone Contractor - = Address L License No. + Phone TYPE OF WELLIPUMP: NEW WELL L.l-. WELL REPLACEMENT JD DESTRUCTION,P PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER C3 DISTANCE TO NEAREST: SEPTIC TANK , , SEWER LINES DISPOSAL FLD. ' PROP. LINE ^ FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation�_.__�_-- Dia. of Well Casing L!'DomesticlPrivate Q1 Pravel Pack Cs Tracy Type of Casing '.: _% Specifications Vi Public [-7 Other !-1 Delta Depth of Grout Seal � � Type of Grout __.__... I Irrigation Approx. Depth I I Eastern Surface Seal Installed by "' -- Repair Work Done l.] Type of Pump ;!__ l__ H.P. t State Work Done .- r Well Destruction El Well Diameter Sealing Material hop 501 -- Depth Filler Material IBelow 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms : Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total lengthtsize FILTER BED 0 Distance to nearest: Well Foundation Property Line `~ SEEPAGE PITS 11 Depth Size Number _ SUMPS l_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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:"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 California." The applicant must Il for all re 'red inspections. Complete drawing on reverse side. Signed X /7 Title: .v�Id ,tC Date: 7-331"'Ug FOR DEPARTMENT USE ONLY 7 Application Accepted by Date -7 } Area t r- I Pit or Grou Inspection by at Final Inspect' by Rat l T Additional Comments: 4 ❑ Stk 466-6781 © LA 369-3621 El Manteca -7104 © Tracy 835-6385 Applicant- Return all copies to; Environmental Health Permit/Services 1601 E. Haxelion Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE FERMIT'NO. INFO 4-