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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA r Telephone (209) 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. 4 .: Job Address Cit Lot Size.L b s PM Owner's Name v .J� �� d PhoB¢7 i � 1 JS,_ No Z- hane� Contra?//'t19r-� l TYPE OF WELL/PUMP: NEW WELL.14— WELL REPLACEMENT DESTRUCTION ❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TD`�NEAiiEST'SEPTIC TAMC'_„�'"`�5EV11ER`LINES�”` � �`'"��IaISP05A�l�FL'D:""�`"� "PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOJVS ❑ Industrial V49rlen Bottom ❑ Manteca Dia- of Well Excavation...,.�.. � Dia. of Well Casing C44k"ri VilctPrivate ❑ Gravel Pack ❑ Tracy Type of Casing / L Specifications + f'l Public Cl Other � ❑ Delta Depth of Grout Seal Type of Grout - A-it tfaation Approx. Depth I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, Its - State Work Done Well Destruction ❑ Well Diameters Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION I l 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 SEPTIC TANK ❑ Type/Mfg} Capacity No. Compartments 111 PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS= Ll- Distance to nearesti—Well 'Foundation— - Pio7p-ety Line DISPOSAL PONDS ❑ f 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 I 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 must call for all equired inspections. Complete drawing on reverse side. Signed X� a Title: FOR DEPARTMENT USE ONLY G� Application Accepted by by Dace `-� Area t Pit or Grout Inspection by Date a l� �7 Final Inspection by < � Date .a42,2- t--e_c ilii y� t Additional Comments: F ❑ Stk 466-6781 ❑ Lodi - 621 ❑ Manteca 1323-7104 ❑ Trillcy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT NO. INFO �y-CASH + EH 13-24 ME EH 1429 riHsl //'l /QST_ 7 c�