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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862for we /pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address/ - City t Size PM Owner's Name L /r Css-A Phone 7X-", ", Co or Adr ss l �€cenPhone 'l / TYPE OF WELL/PUMP: u NOVWELL ❑ VdELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of-Well Excavation' Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H:P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'i, Depth Filler Material (Below 501j' ' TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION {.I_DESTRUCTION�(No septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence_ Commercial_ Other i 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 PKG. TREATMENT PLT. ❑ _ Method of Disposal jDistance to nearest: Well Foundation Property.Line LEACHING LINE LI No. & Length of lines �.. Total length/size NL FILTER BED '❑ Distance to nearest: We11 Foundation ' Property Line SEEPAGE PITS *l I Depth Size Number SUMPS Ll 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 laws, and r 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."Contractors 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 c�foralfliredinspections.-Complete-drawing-on-reverse side. Date.0 �^/0—J Si Title•:�/�� FOR DEPARTMENT USE ONLY ` k Date `l —.62> Area 1 Application Accepted by Pit or Grout Inspection by .I' Data Final InsprAign by Dater/`,.! - N Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-366 ❑ Man eco 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVEDRECEIVED BY DATE PERMIT'NO. INFO �j +.EH 13-24(REV.1/R 5) S r-� [I L j r �7 EH to-26