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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ 1 4 (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ) yl.' __ .. City � Lot Size PM } Owner's Name Address Phone I 1 ,P Contractor ,/ 1.!(�t Le4— Address g License No. Phone r r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ N DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing= PV 6\ k Specifications LL ED C1 Other ❑ Delta Depth of Grout Seal Type f Gr ut dz - 1 F1 Irrigation _Approx.pth-vw�❑ Eastern Surface:Seal_$Instailedo-by-T 1.e1 , �1^ _ Repair Work Done ❑ Type of Pump" H.P. _ State Work D ne i ` Well Destruction Well Diameter s Material (to-p50') i w.�..•s f Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION`OJ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is (� 1. � available within 200 feet.) Installation will serve: Residence—1 Commrcia'yI_ Other Number of living units: Number of bedpoorr('s Character of soil to a depth of 3 feet! ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal C� li Distance to nearge�st:1 1Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: W ell Foundation,- Property�ne DISPOSAL PONDS ❑ # `w 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 tele following: "I certify that in th performance of the work far which this permit is issued, I shall not employ any person in such manner as to become sul iectlto workman's compensation laws of California."Contractor's hiring or ub-contracting signature certifies the following:"I certify that in the performance o�..the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicanrmall for II r d inspections. Complete drawnng n reverse side.-.��, ' ir Signed X Title: r Date:�(,�.� . � . JnEIPAg�RM1ENT USE ONLY ft Application Accepted by / Date Area Pit or Grout Inspection by D 7/ f Final Inspection by Date ditional Comments: t , .Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca t 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Oermit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE [,PERMITVN0." +EH13.24IREV.si551 A" EH 1425 3S- x55do