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APPLICATION FOR :.illiii �I r'SAN JOAQUIN LOCAL HEALTH DISTRICT � + 1601 E. HAZEL T ON AVE., STOCKTON, CA r f 'jU5" Telephone (209) 466-6781 /-Vje57 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED y /quin � L�VIRONIE ITAL HEALTH (Complete in Triplicate) �ERM(T�SEf2VlCES Application is hereby madeJoaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with Sounty 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 /� '� City j�/� �/� ^-� Lot Size PM Owner's Name C�l� � Address /Z , � Phonez'� Contractor 1✓/�®�l? F-?3;> Add ' Ogg S ress / G!J! License No. 1c Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,R/z014,-�FSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation .W Domestic/Private D Gravel Pack ❑ Tracy Dia. of Well Casing Type of Casing Specifications M Public n Other ❑ Delta Depth of Grout Seal I I Irrigation ation Type of Grout �.Approx. Depth i 1 Eastern Surface Seal Installed by ._ Repair Work Done LJ Type of Pump — �✓0 H,P, f State Work Done - ®.� �`�' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other availa !e-within 200 feet.) Number of living units: Number o bedrooms i1 Character of soil to a depth of'3 feet: "J SEPTIC TANKWater table depth ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments { J Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINT_ ❑ No. & Length of es Total length/size , FILTER BED ❑ Distance to arest: Well_`_ Foundation Property Line SEEPAGE PITS I I Dept Size_— _ Number SUMPS L7 Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line ! 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 Distriet. 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." Contractors 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 II pequired ' ti ns. Complete drawing on revers side. 01 Signed X Title: � ��— C� Date: _ p FOR DEP RTMENT USE ONLY Application Accepted by _O Date Area Pit or Grout Inspection by Date Final Inspection by q Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95291 FEE AMOUNT DUE: AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT'NO. +.EH1 -24fREV,tin55 EH 1429 u