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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2�F3s- (Complete in Triplicate) cation is Application is hereby made to the San Joaquin Local Health District for a permit to co tract and/or install the Rules work herein (Regulations of the S. This an'Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1 for lipyq+p f // Local Health District. G/ ��% /e r A li n t/ #1 r1 (.K.1G G%1 4 City of Size Edi PMda Address X11 'moi /! Phone Owner's Name Address r /7 y Cf %��(r License No, Phone Contract�/i`�rSA � ddress t � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/Private F1 Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing C1 Other ❑ Delta Depth of Grout Seal --Approx. Depth I I Eastern Surface Seal Installed by Type of Pump H.P. State Work Done _ Well Diameter Sealing Material Itop 501 De th Filler Material (Below 501 Dia. of Well Casing Specifications Type of Grout p - TYPE OF SEPTIC WORK: NEW INSTALLATION RE'PAlR/ADDITION l I DESTRUCTION I I availablec system within200 feet.) if public sewer is Installation will serve: Residence Commercial —_ther Number of living units: `f Number of e ooms Character of soil to a depth of 3feet: Water table depth / I r _ SEPTIC TANK Type lMfg �-a Capacity No: Compartments PKG. TREATMENT PLT`•❑ / Method of Disposal f Of Well f Distance to nearest: WelFoundation I Property Line c25L_ LEACHING •LINE` c No. & Length of lines ~ Total'length/size_/ �x FILTER BEi� ❑- Distance to nearest: Well - Found'ation Property Line— � SEEPAGE PITS Depth Size -- Number 1,599 SUMPS Ll , Distance to nearest: Well 1__ Foundation - . Property Line �•� -- DISPOSAL PONDS, -'-0 - 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 agont's signature certifies the following: "I certify that in the performance of.the work for which this permit o issued, I 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: "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 fo re irod inspections- Complete drawing on reverse slid / ' Signed X Date: Title: j FOR DEPARTMENT USE ONLY o Application Accepted b _ Data it r Grout Inspection by bate Final Inspection by u� `[ Oates 7 G Additional Comments: 1- 0 Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LJ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1011 E. Hazelton Ave., P.O. Box 2009, St:.., CA 95201 `� f �. EH 13-24 (REV. I/ H 5 Di tr-23 FEE AMOUNT DUE AMOUNT REMITTED C S41 RECEIVED BY DATE PERMIT NO._ INFO