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APPLICATION FOR PERMIT s.l:k , . 'i f24 SAN JOAQUIN'LOCAL�HEALTH DISTRICT I� w ' 7&7�. : l 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1=YEAR FROM DATE ISSUED# {Complete in.Triplicatel 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 f i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forwell/pump and the Rules and Regulations of the San Joaquin l Local Health District. "� Jab Address City `' •a 'Ui: Lryot Size PIM f i Address ' Phone Owner's Name �L-�°` - _ r P Contractor�Z:t4 e1 e '-; Address r L(, License No.k0fi� Phone TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation : Dia. of Well Casing A E�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 'i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by LI ( Repair Work Done Type of Pump /�r.�-B-- H.P. l r')- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') L , Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) rN Installation will serve: Residence_ Commercial Other--- ` G Number of living units: Number of bedrooms S Character of soil to a depth of 3 feet: { Water table depth SEPTIC TANK ❑ Type/Mfg -"—Capacity �-4 No. Compartments PKG. TREATMENT PLT. ❑ dam Method of Disposal Distance to nearest: Well - Foundation'77.-! —Property-Line LEACHING LINE ❑ No. & Length,of lines Total lerigth/size FILTER BED ❑ Distance to nearest: Well Foundation R Property Line w SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line. . DISPOSAL PONDS ❑ hereby certify that I have prepared-this-application-and-that-the-W&k"will"be done in accordance with'5an 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: 'Tcertify 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 ca 11 for all required inspections. Complete drawing on reverse side. `c Signed XTitle: - _ F Date: OR DEPARTMENT USE ONLY ✓� 7 4 Application Accepted by Date Area ` Pit or Grout Inspection by Date Final lnspection by Date ?d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 95201 t ` FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH + EH1324(REV"1/8s) EH 10.26