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f , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 i PERMIT EXPIRES 7 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 �� r City �``"`� �'��r Cat Size PM Owner's Name __V N __ f � Address / Phone ,� may. � CGntractor fz/ lQ f{�Qrj�� License Nohone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR J§:� 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 JB �j'DomesticlPrivate ❑ Gravel Packs ' ❑ Tracy Type of Casing Specifications / FI Public 0 Other ; Cl Delta Depth of Grout Seal Type of Grout __ I I irrigation _.Approx! Depth I t Eastern 'Surface Seal Installed by Repair Work Done I� Type of Pump H.P._ =•State Work/Surface �•5 'C jSew., Well Destruction ❑ WellDiame er � Seating Material {top 50'1Depth 10 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permiavailable within 200 feetInstallation will serve: Residence____ Commercial— Other Number of Jiving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. CompartmentsPKG. TREATMENT PLT. ❑ Method of Disposa ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well 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 DF%trict. 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 per, - such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the owing: certify that in the perfo ce of the work for which this permit is issued, I shall employ persons subject to workman's comp, tion laws California." The appl' ant st or all r u' ons. drawing on ryr�y�side. f �j Signed Title: -� Date: FOR DEPARTMENT USE ONLY 'Z7-- Application Accepted by �1dalVNC�-M Date Area Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE , INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT'NO. t.EH 13-24 IREV.t/H 51 EH 14-28