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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (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 �7 �S`r rlr �[�yi�eJ _ City Lot Size S PM ��jj Owner's Name Address L� Phon6/12 9Y4-5119 al rYYieQ a GddS $1� L'T12iJ1'1��'.2. 25 �.-M��tett�J$TockTZ> CS�� -12%6�'!r5'} a"- & 91t2- ContractorAddress - License No. Phone O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - -- r DISTANCE TO NEAREST: SfPTIC_TANK Sa _SEWER LINES SO DISPOSAL FLD PROP. LINE �o FOUNDATION /D• AGRICULTURE _WELL � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -� PR6BLE1i 4iiEA -CONST RUCTION SPECIFICATIONS ❑ Industrial - -•--- -- ❑ Open Bottom -- ❑ Manteca-•.- Dia, of Well-Excavation Dia. of.Well Casing ❑ Domestic/Private -� ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll 01her Ll Delta -Depth of Grout Seal' ~V " -`Type of Grout+" "- I I Irrigation ... _.Approx. Depth . I 1 Eastern-.,..-.,..__ ..Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction © Well Diameter. Sealing Material (tpp 501 -- - Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK_ NEW INSTALLATION I.) REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is ti - available within 200 feet.) -- Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS D Distance to nearest: 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 Diltrict. 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all uired i ctions. Complete drawing oneverse ideWl E Signed X '/'CclilQ e Title: aDate: -7 - � - `� F EPA T USE ONLY�rn Application Accepted b / S� C Y Date -� Area Pit or Grout Inspection by Date Fina! Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 E Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO, . 6H 13-21/REV,I/x 51 S��