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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT No�1 ( N�Y' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209] 466-6781 N, �1A�Wwk PERMIT EXPIRES TYEAR FROM DATIW.ISSUED A / (Complete in Triplicate) n Joa uin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the Sa q made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. of Size Q i City X PM Job Address -11) QQ 11- (/ Owner's Name ./J Address ^� �IA � 1 Phone "�4- 1License No. Phone Contractor r I Address TYPE OF WELL/PUMP: )NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION P SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Industrial El Open Bottom Manteca Dia. of Well Excavation I-] ISpecifications ❑ Domestic/Private 1-1 Gravel Pack LJ Tracy Type of Casing 1'1 Public I-I Other it Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth 1 ! Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material /top 501 Depth Filler Material /Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I 1 DESTRUCTION lNosepttic system ithin 20permitted if public sewer is ailable 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 Method of Disposal PKG. TREATMENT PLT. Q r ` Distance to nearest: Well Foundation Property Line I r - LEACHING LINE ❑ No. &'Length of lines Total length/size I FILTER BED ❑ Distance to pearest: Well Foundation Property Line t � SEEPAGE PITS I I Depth Size Number r SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a 1 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, f 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 must call for all required inspection2. Complete drawing on reverse side. c5,_2�„ N. 4Z Title: Date:!`� MPAIRI.TMENT USE ONLY { lugDate Area Application Accepted by r / Pit or Grout Inspection by Date Final Inspection by Date Tn Z2 t Additional Comments: t ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Mante 823-7104 Q Tracy 835-6385 { Applicant - 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 C SH RECEIVE/}BY DATE PERMIT NO. I INFO + EM 13-24/REV.s/x al EK 14-26