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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 1209! 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED ' : AA .(Complete in Triplicate) .. a. ,. 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 compliancOUlth San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. l Job Address 1, Aif city' Lot SiPM Owner's Name Address - b Phone- - 3. [1 f ` 1 ContractorAuu, 6/7 �AAAS' Address ' ��+.w License No � Phone r. TYPE OF WELL/PUMP:-;.� ;;; NEW WELL ❑�z...:.„�,..�,.WELL;REPLACEMENT 17. r - DESTRUCTION ❑ ; e i "' PUMP INSTALLATION©�„,_,': ` � SYSTEM REPAIR i❑-t% OTHER ❑ y DISTANCE TO NEAREST SEPTIC TANK SEWER LINES ' ',DISPOSAL FLD. rF�PROP. LINE i t FOUNDATION AGRICULTURE--WELD eOTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA � CONSTRUCTION SPECIFlCATIONS •V •r ❑ industrial, ❑ Open Bottom 's ❑ Manteca Dia. of iWell Exc'svationDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack R3 ❑ Tracy Type of.&sing Specifications s ❑ Public"' ❑ Other w�? ❑ Delta Depth,of Grout Seal �f� ' Type of GroutLP ❑ Irrigation --Approx. Depth ❑ Eastern Surface-Seal Installed by 1 I Repair Work Done F1 Type of Pump "�" H.P. 1State Work Done . -� r Well Destruction ❑ Well Diameter `"+ Sealing Material (top 501 - i Depth Filler Material (Bejow,501) % t' _V TYPE OF;SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is °• �' c'd available within 200 feet.) .0 ° Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: 0/-,22/ -- Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity No. Compartmentsre PKG. TREATMENT PLT. ❑ Method of Disposal" Distance to nearest: Well Foundation Property.Lyme..4 LEACHING LINE t y [3 No. & Length of lines 2-40' 3_5Z" Total length/size ` ` ❑7Drstance to FILTER BEDnearest: Well „Foundation1Z PropertyLine IYYI w+rw.�.rr SEEPAGE PITS ;` LlP Depth ZS Size ... 'lod ri f Number SUMPS c + Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 4,—L] j 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,J shall not '.., - employ any person in such.manner as to become subject to workman's compensation laws.af California:'w Contractors hiring or sub-contracting signature r certifies the fdllowing: "I certify that in the performance of the work for which 4his permit:s issuedf l shall employ persons subject to workman's compensa- tion laws of California.". The applicant f r"ah uire(inpections. Complete drawing on reverse sl N�"Signej_ Title: X Date: FOR aDEPART MENT USE ONLY " Application Accepted by ji Date a C J alPit or Grout Inspection byu 1 -Date Final Is#pection by a.. r„ . Additional Comments:-: 'l 1V 17P ?In VW ❑ Stk 466-6781"”" ❑ Lodi 369-3621"` "�❑,Manteca. .823 7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Per Services 1601 E!Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT'NO. r INFO ' CASH -`+•EH13-241REV.i/ssl 1 EN14-26 ;. -