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V APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;; II (Complete in Triplicate) construct l Application weiaby ith SanoJoaqu n CounJoaquin ty Ordinance NHealth o. 549 for sewage permit o 1862 for well/dpump ainstall nd the Rules and Regulations of the Sanapplication Joaquin Local Health District. a r � City 4_J 1 Lot Size � PM Job Address �' + �' Phon ' — I Owner's Name ��+ Address ., �t ,` f Contractor.] + `moi' Address/ �+ N 0�icenseNo� JZ�"?Phone�r`�^�� Y TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 174 DESTRUCTION ❑ 1 PUMP INSTALLATION 5a.-5a.— _ SYSTEM REPAIR Q _ , .OTHER El .. DISTANCE TO NEAREST: SEPTIC TANK !Z)t rSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S Sty ❑ Industrial:' *10pen Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing O # A-Mmestic/Private ❑Gravel Pack ❑ Tracy Type of Casing I Specifications t"1 Public T f-1 Other Cl Delta Depth of Grout Seal ts Type of Grout -. I I Irrigation Approx. Depth 13 Eastern Surface Seal Installed by Repair Work done ❑ Type of Pump H.P, State Work Done Sealing Material stop 50'1 O { Well Destruction ❑ Well Diameter 9 , Depth Filler Material l8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDiTION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: `' Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑.., Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 171 Distance of Disposal (7 t Distance to nearest: Well Foundation Property.Line } fu LEACHING LINE ❑i No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I 1 Depth Size Number $ ! SUMPS ❑ Distance to nearest: Well Foundation Property Line F S` t - {r, DISPOSAL PONDS ❑ - _ I hereby certify that I have prepared this application and that 1He'w0rk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the`San Joaquin Local Health Di%trict. .eT 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractdr-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." ` � �r I The applicant must calk f r all required inspections. Complete drawing on reverse side. Signed X Ue�� 8'�S k Title:�t�4-w._�.r��' ` Date: o .r r. FOR DEPARTMENT USE ONLY 1, t, Date Area Application Accepted by y V. Pit or Grout Inspection by A Date V Final Inspection by—� Y/_� — Date 0'2� ox Alt ;S6 ' - Additional Comments: + ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Mani ca B23-7104 V ❑ Tracy &35-6685 OK 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 RECEIVED BY DATE PERMIT NO. INFO +.EH 13-241REV. /851 I 1 `3 EH 14-26