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APPLICATION FOR PERMIT ot ® SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �j° (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wtr(cyhe sir�tektri�ed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules a egulations of the San Joaquin Local Health District. Job Address /tT� � Pj, City Lot Size PM Owner's NameA7P>,F��'t+c-fAddressX?r. Phone ys�v ra Contra Address 6 - , �' �tcense No. �^ Phone � i tj;� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION l SYSTEM REPAIR ❑ OTHER ❑ j 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 >.Qomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump-4-x.1-1 H.P. j51&QState Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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 Di1tri& 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, I shall employ persons-subject to workman's compensa- tion laws of California." The app1' call for all wired inspections. Complete drawing onn]reverse side.' Signerd„X L9-- Title:j�l.�¢----- Date: I � 8 0EPART�SE ONLY C� f�J Application Accepted by 5L ,_,L ^ Date Area Pit or Grout Inspection by Date Final Inspection by Date//Zl• k� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CK RECEIVED BY DATE PERMITNO. ti INFO CASH ♦.EH1 3-241REY.I/11b) E EH 14-28 4 t