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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 9 Telephone (209) 466-6781 PERMIT EXPIRES TY"EAR FROM DATE ISSUED (Complete in Triplicate) i 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 C unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L� Job Address / City Lot Size PM Owner's Name t� � "• �3 Address " ' Phone Q � ` y� ContractorX� r,.__ Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL Cl` WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTIALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l 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 Weil Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications \� F-1 Public Cl Othe�(I+ " �;{ {, Delta -� Depth of Grout Seal Type of Grout I i Irrigation �_,Appr x:-Depth._{i`I_Eastern-.,a -Surf ace-Seal-Installed.by-�- = ---.------ --- V Repair Work..Done ❑ Type of Pump H.P. 11. State Work pone Welt Destruction ❑ Well Diameter Material (top 50'),, j Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRJADDITYON i I DESTRUCTION I (No septic system permitted if public sewer is f i4 available within 200 feet.) .. 3 insfalfetion will serve: Residence s 1 Commercial_ Other' ,ten y TII.°�n"ber of living units: Number of bedrooms Character of soil to a depth of 3 feet v Water table depth SEPTIC"TANK ❑ Type/Mfg f Y" .` Capacity ! ', R0-N& Compartments C. PKTREATMENT PLT. D `� t Method of Disposal Distance to nearest: Well t Foundation 9 Property.Line LEACHING LINE CI No. & her�ngth_of lines Total lengifi/`site— Flt-TER BED ❑ Distance to.nearest: r+ Foundation Property Line SEEPAGE PITS 11 Depth Size Number Q SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS: ❑ I hereby certify that I"have-pfepared-this-applicatiomand-that the.work-will-be-done-in accordance-with-San Joaqujn'county ordinances, state laws, and A rules and regulations of the San Joaquin Local Health district." g:"T certify that in the'performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the foltawin employ any person in such manner as i6become subject to workman's compensation laws of'California."Contractor's hiring or sub-contracting signature certifies the following: "1 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 ust call for all required inspections. Complete drawing on reverse side. Signed X �J Title: l0 / " , Date: 6 ll FOR DEPARTMENT USE ONLY Application Accepted by date 2 Area rQ Pit or Grout Inspection byw Date Final Inspection by_ i l Date U Additional Comments: �� i20 Q Stk 466-6781 ID Lodi 369-3621 LI Manteca a23-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNTREMITTEDASH RECEIVED BY DATE PERMIT'NO. +.EH -24lH 2 EH 14-26 EV.