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i 3 I L ✓IG l r APPLICATION FOR PERMIT �I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1'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 se age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address City Lot Size PM t Owner's Name Q Address 33 AJ. Phone-1166 -170 IU .d��50 Contrac "'Address ��flLicense N,36 P Phoneq7 r ./ .S TYPE OF WELL/PUMP: ' yNEW WELL ❑ ^t WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ]V FOUNDATION AGRICULTURE WE.LL+"'" : OTHER WELL PITS/SUMPS INTENDED USE TYPE OF PROBLEM AREA�ONSTRUCTION SPECIFICATIONS LJIndustrial ❑ Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack �❑ Tracy Type of Casing Specifications i'1 Public ❑ Other i� 171 Delta Depth of Grout Seal Type of Grout I I Irrigation _-App(ox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50') Depth !� t Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial_ Other i Number of living units: Number of bedrooms �i Character of soil to a depth of 3 feet: Water table depth ,w t SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ iM ; Method of Disposal Distance to nearest: Well Foundation Property Line A LEACHING LINE Ll No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Li Distance to nearest: well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquinicounty 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, 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, I shall employ persons subject to workman's compensa- tion laws of California." i � r _ Alts 1 [� The applicant mus call for 1 required inspections. Complete drawing on reverse side. Signed yy Title: Date: 3 �I FOR DEPARTMENT USE ONLY i Application Accepted by ff: Date ✓ r Area Pit or Grout Inspection by iI Date J /Final Inspection by 1� G-- ^-�` LL'` Dat4 t Additional Comments: _ 1_3?1 ,2 7 F3 /,s�Wl brunA- li-4 yJif{ ' 1 h at t 4-0 ❑ Stk 466-6781 ❑ Lodi 369-6621 ❑ Manteca -7104 ❑ Tracy 835-6385 -6 G-c� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT:NO. �. C/6 + EHt3-24{gEV.riH51 r ar � / EH 14.26 f/ s I�