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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 4SCANED 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. ;, r . . r Job Address City SN Lot Size PM Owner's Name !'Z�P, fT4W_If Address Phone Contractor A/� � dress License No. Pll TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C „ PUMP INSTALLATION 50 iQ6V/+�JH+ STEM REPAIR ❑ OTHER ❑ vr`� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUI PS _ INTENDED USE TYPE OF WELL. 1, PROBLEMIAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E3Open 6ottoll ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing i �MomesticlPrivate ❑ Gravel �ack C1 Tracy � Type of Casing Specifications � ❑ Public ❑ Other i ❑ Delta k Dell Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth ❑ Eastern#� )ffsurfaC6 Seal Installed byRepair Work Done ❑ Type of Pumpx� H.P. 2— State Work Done Well Destruction ❑ Well Diameter Sealingll ateriall(top 50') ^ dtl Depth Faller Material (Below 501 _ 4si�,[ ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIIR/ADDITION DESTRUCTION ❑ (No septic system permitted.if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ i�Othei•. Number of living units: Number of bedrooms N Character of sail to a depth of 3 feet: r.1 a Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal JI. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines f Total length/size �M "` FILTER BED ❑ Distance to nearest: Well Foundation W Property Line L 4 Ilk ' SEEPAGE PITS ❑ Depth Size 1 , Number �M jSUMPS ❑ Distance to nearest: Well Foundation _ Property Line i DISPOSAL PONDS ❑ j I hereby certify that I have prepared this application and that I is work will bei.done A4 accordance wrath San Joaquin county ordinances, state laws, and A rules and regulations of the San Joaquin Local Health District I r �� Home owner or licensed agent's signature certifies the followi : "I certify th�t in th,perfo�m1nce of the work far which this permit is issued, I shall not employ any person in such manner as to become subject to wo man's Dom pe sal6orhawlll California."Contractor's hiring or sub-contracting signatureh certifies the following: "I certify that in the performance of the r ork for which t isW. 4it is issued, shall employ persons subject to workman's compensa- tion laws of California." e i...... The applicant qv4t c II fo allr Pd inspections. Complete drawing on-revise de. Signed 9 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date C� G Area L& 2 Pit or Grout Inspection by Date YFinal Inspection by r I� Date r� J� 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1823-7104 "t❑ Tracy 835-6385 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 cG FEE 6 INFO AMOUNT DUE AMOUNT REMITfrED CASH RECEIVED BY DATE PERMIT'N0. + EH 13-241REV.i/a5) ^� c EH 14-26 .? ^�• 0 F t e f 'I