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3'APPLICATION FOR PERMIT � I SAN JOAQUIN LOCAL HEALTH DISTRICT Y n 1601 E. HAZEL T ON 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City F Lot Size-040'U,57- PM Owner's Name Address27 Phon Contractor ' Address erase No. Phone t. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial EDOpen Bottom 17 .Manteca Diaof Well Excavation I] LJrt �e ''!!,,,,_ "�yC. Specifications Dia. of Well Casing ff i Domestic/Private Gravel Pack ❑ Tracy Type of Casing_' p ��i,7 1-1 Public Cl Other Cl Delta Depth of Grout Seal ^orf 5�. T pe of Grout �a I I Irrigation ____.Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destructio ❑ Well Diameter _ --...-_:`L_ Sealing Material (top 50') �Y_Y1e��' Aon'r•�o ri+L (3-1 Depth -,1 /�, 0 AP Filler Material (Below 50'j !'1t/I, -� TYPE OF SEPTIC : NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION 1t=4,(Nd septic-system permitted if public sewer is c available WkAinr200_feet.) Installation will serve: Residence_ Commercial— Other r 04i3 Number of living units: Number of bedrooms i Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. © Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r 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 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."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 applic m st call f all re re inspections. GempFele�caurigf}o eyes side �rO�'�+'meq �1�G� Signed / J f: Title: � Date: �• hA � +X« DEPARTME USE ONLY Application Accepted by Date Pit or Grout Inspection by Date `��FinaI Inspection by Dat O t� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1`12 t(;U EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO CASH 3 I r EH 13-241REV.v/N5) EH[4-2e