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II APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466_6781 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 SariJoaquin County Ordinance No.549 for sewage or No. 1862 for.weh/pump and the Rules and Regulations of the San Joaquin Local Health District. ;1�3 Job Address �.l L. .. Q LL - '� C Q dC�cks: ryLot Size v!`C PM Owner's Name ` Address p�-jPhone bQ7r A JC, 40 �f �►igddress S.�+M 17 d 24 Q TYPE OF WELL/PUMP: License No. Phone PUMP NEW WELL K WELL REPLACEMENT p. DESTRUCTION ❑- "'" MP INSTALLATION 3K. r SYSTEM REPAIR ❑_ �.& { DISTANCE TO NEAREST: SEPTIC TANKOTHER ❑ (Z_ SEyyER LINE5 r� iE DISPOSAL FLD, PROP. LINE FOUNDATION .XJ a – AGRICULTURE WELL" r OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca If Dia. of Well Excavation Dia. of Well Casing r t Domestic/Private ❑ Grave! Pack [2 Tracy I ❑ Public ❑ Other Y Type of Casing Specifications ❑ Delta Depth of Grout Seal E2Irri anon � Type of Grout 9 C.fC i g —�pprox. Depth ❑ Eastern Surface Seal Installed by y Repair Work Done ❑ -Type of Pump r H p �, �"�' Well Destruction ❑ Well Diameter State Work Done Sealing Material ftop 50') Depth Filler Material`(Beiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ DESTRUCTION ❑ (No septic system !� permitted if public sewer is Installation will serve: Residence available within 200 feet.) � Commercial� .Other-��_ . Number of living units: Number of bedrooms 1 .� Character of,soil to a depth of 3 feet: i SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal # Distance to nearest: Well Foundation a, Property Line LEACHING LINE ❑ No. Length of lines FILTER BED o• Total length/size ❑ Distance to nearest: Well Foundation I Property Line �^ =SEEPAGE-PITS—�O D,epth ❑ ..D' Size Number SUMPS • _ stance to nearest: Well Foundation DISPOSAL PONDS [2 ;j� i Property Line 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. Home owner or licensed agent's signature certifies the following: F employ any person in such manner as to become subject to workman's compensationtlthe aewsoof California."Contractor's rmance of the work for Ihiiringch �or sub--contracs permit is tinglsignaltuot certifies the following: "I certify that in the performance of the work for which this tion laws of California." i! permit is issued,I shall employ.persons subject to workman's compensa The applicant m t call fora require mspectio . Complete drawing on reverse si e. Signed X , � ]��, Title: � o Date: C FOR DEPARTMENT USE ONLY Application Accepted by i� q t DataArea Pit or Grout Inspection by Date Loma. i Final.Inspection b Date I ' Additional Comments: 1. i ❑ Stk 466-6781 ❑ Lodi 369= 1 ❑ MantecaAW-7164 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT.',DUE INFO AMOUNT REMITTED CASH "RECEIVED BY DATE PERMIT N0. : ID+ EHEYt/651 EH 74-M � 4 /f5V+ ;