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r A APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT Ft � 1601 E. HAZELTON AVE., STOCKTON, CA Ink Telephone (209) 466-6781 1 �. PERMIT EXPIRES TYEAR FROM DATE ISSUE �� 1 , 2 7 (Complete in Triplicate) L iROMMENTAL Application is.hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work&&�iyi ��edWion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation n Joaquin Local Health District. Joh Address City Lot Size PM Owner's Name Address pC 41t Phone 36� 41 Contractor Address icense No Phone -U TYPE OF WELL/PUMP: NEN WELL ibY WELL REPLACEMEN ❑ DESTRUCTION CI rP-UM^P� LiA INSTA70 SYSTEKrREPAIR ❑ O ER L7 DISTANCE TO NEAREST_: SEPTIC TANK R LINES ISPOSAL-FLD PRO --LINE- FOUNDATION INE-FOUNDATION AGRICULTURE WELL J1tdLAaTUER WELL PITS/SUMPS,_# r INTENDED USE TVP P-01` WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS !� ❑ Indu trial pen Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing amestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications '1 Public I - • f! Other. Cl Delta Depth of Grout Sea! ype of rout _ { ' _. I Iflrrigation i —..Approx. Depth l I astern Surface Seal Installed by Repair Wbrk Dnne LIType of Pump ~ H.P. State Work Done a Well Destruction ❑ Well DiameterSealing Material (top 50') Depth ^ Filler Material I Below 501 \` TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial_ OtherI Number of living units: Number of bedrooms x Character of soil to'a,depth of 3 feet: Water table depth SEPTIC TANK / ❑ Type/Mfg�.� . Capacity No. Compartments PKC. TREATMENT PLT.'❑ Method of Disposal Distance to nearest: Well foundation Property Line '? LEACHING LINE ❑ No.$ Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number_ - .- ,-- SUMPS IT Distance to nearest- r Well Foundation Property Line DISPOSAL PONDS ❑ 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, 1 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 xhis permit.is.issued, Lshall,employ persons subject.to workman's,corilpensa. tion laws of California." The applicant st call f- all r u' ed i specti_ons.`Complete drawing on arse si e. ` Signed X 1 Title: Date: L7 V, Pt F EPARTAAENT USE ONLY Application Accepted by _ 1 C/ r�p�� ®/ Date Area Pit or Gro �spa f by Date Final Inspection by Date Addition om ' s: E] Stk -6781 ❑ Lodi 369-3621 Manteca -7104 ❑ Tracy 835-6385 v Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMIT'NO, INFO GASH + EH 13-24 1 REV.I/H 51 ! EH 14-26 1 ` o