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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 f Telephone (209) 466-6781 / z 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 .compliance with San Joaquin.County Ordinance No.549 for sewage or-No1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - Job Address .- No . City—Z=j., Lot Size PM Owner's Name _��l��u �I r; Address S �t J r2d S �fXPhone (06TJ J�P2 2 yf ' 9 323 p ►'3�5 Contractorly'�rLoAlVwAddress 00 Ei.��Q� _ License No.�AOBa� Phone t TYPE OF WELL/PUMP: NEW WELL 6 WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ lndustrla) .❑ Open Bottom ❑ Manteca Dia. of Well Excavation H `r (2 'r - Dia. of Well Casing ❑ Domestic/Private 9 Gravel Pack ❑ Tracy Type of Casing ❑ Public(9""R ❑ Other Specifications ❑ Delta Depth of Grout Seal ' Type of Grout ❑ Irrigation 4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �. H.P. -� Well Destruction ❑ Well Diameter Sealing Material (top 501 State Work Done 'b Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer e Installatio ill serve: Residence Commercial available within 200 feet.) , Other Number of living Number of bedrooms Character of soil to a dept eet: SEPTIC TANK F] Type Water table depth ype/Mfg Capac- No. Compartments PKG. TREATMENT PLT. ❑ l Distance to nearest: Well Foundation Method of Disposal C Property Line LEACHING LINE ❑ No. & Length o ' es Total length/size FILTER BED ❑ Dist o nearest: Well Foundation erty Line SEEPAGE PiTS ❑ Depth Size .0 " Number SUMPS LJDistance to nearest: Well Foundation OSAL PONDS ❑ .� Property Line 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, 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." The applicant must call for all requi 0 d inspections. Complete drawing on reverse side. Signed �� P Title: Lsw ate:l� Ia c.. E ONLY Application Accepted by Date Area " Pit or Grout Ins do y Date?----( Final inspection by r Date Additional Com ents:� ❑ Stk 466-6781 ❑ Lodi 1 ❑ M a -7104 ❑ T y 835-Mffi I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 01 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH, HECEIVED.BY DATE y� PERMIT'NO, + EH 13-24{REV. a s) 2S/}y)7C ` EH 14-20 � .7 "V `. . sow g� a,