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APPLICATION FOR PERMIT s5r� 1,F SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA 1AAR J Telephone (209) 466-6781 t PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ENVIFomENTAL HEALTH y . (.Complete in Triplicate) I'MMIT/SERVICES• 0 ' 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 i Local Health District. ,/ j. Job Address IaP F�°j?St< IJT �J2C V City COf Lot Size PM t ` - Owner's Name V 2y15 , a e Address � Phone (Zn g s S Contractor �1 C Address to - m�' . `��cense No. 16o 7 Phone 6s —o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Sar J )?a,2JA1C,S t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS K INTENDED USE TYPE OF WELL Ir PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack V-Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal < 2:57 ERC Type of Grout 22 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by C Repair Work Done ❑ Type of Pump H.P. State Work Done C Well Destruction ❑ ' Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') Il TYPE OF SEPTIC WORK: NE INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.€ F Installation will serve: Resident Commercial_ Other Number of living units: Nu ber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT. d Method of Disposal Distance to ne est: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Ii es Total length/size l FILTER BED ❑ Distance to nearest: !I Foundation Property Line SEEPAGE PITS ❑ Depth �arest: ize Number 1 Y SUMPS ❑ Distance terll Foundation Property Line • 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. f 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,1 shall employ persons subject to workman's compensa tion laws of California." I The applica must cal ar all required ins trio s. omplate drawing on reverse side. t Title: l-tl000 W A 2 ^C.�r�� bate: Va Signed USE ON OR DEPARTMENT 175E ONLYY Application Accepted by Date Area 2 Q Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE .AMOUNT DUE AMOUNT REMITTED ASH d RECEIVED BY DATEh (�PERMIIT"NO. INFO y� ��-7 7/��