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�. . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r4 to 1.a 04 PERMIT EXPIRES TYEAR FROM DATE ISSUED No ' (Complete in Triplicate) 'Joaquin Local Health District for a permit to construct and/or install the work herein �edThis pplication is Application is hereby made to the Sanq r 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. j Job Address City Lot Size PM Of " Address _„ �'" � Phone Owner's Name r / [� Phon r+�� Contracto Addres � 3 License No. TYPE OF WELL/PUMP: ;NEW WELL 171 WELL REPLACEMENT 0 DESTRUC710 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHERR ❑ { I INF DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P FOUNDATION AGRICULTURE WELL _ y THOP PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing C7 Domesticl Private ❑ Gravel Pack Tracy Type of Casing Specifications L,1 I FI Public ❑ Oth 17 Delta Depth of Grout Seal Type of Grout T\ I I Irrigation —.Approx. Depth I. 1 Eastern Surface Seal Installed by - Repair Work Do ❑ Type of Pump H.P. State Work Done Well Des tion ❑ Well Diameter Sealing Material (top 501 Depth ' •- Filler Material (Below.501_ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION L1 IDESTRUCTION INo septic system permitted if public sewer is { F available within 200 feet.) � ( ; Installation.will serve:` Residence Commercial'_t Other Number of living units:- Number of bedrooms t i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ # f _.Method of Disposal f i Distance to nearest: Well Foundation K "►'Property Line LEACHING LINE ❑ No. & Length of lines Total lengthflsize I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS k1 Depth Size F Number i ' 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 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 compensa- tion laws of California." The applicant st call for all require inspections. Complete drawing on reverse side. 7 Signed X t Title: Date: A DEPARTMENT USE ONLY Application Accepted by Date d3 Area Pit or Grout Inspection by J Date` s ``� "`- Fin Inspection by Dafd�-� 1� VV L Additional Comments; -3 r 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Wealth Permit/Services 1601 E. Hazes eltonrAv� P.O. B'ox�Sik., CrA95201 �- FEE D B INFO AMOUNT RUE AMOUNT REMITTED H RECEIVED BY f n DATEI(� �(PERMIT NO. + EH 13-24{REV.i i n 51 �� ,C?la 3� „U EH 1426 1