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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. r7 �p I /1 �� 1�-� Z / J / �/1 f fT� 1 , fY J� r:..S//1L�L /4]!1 DRA Owner's Name o4Q91VJA1 15 kA Address `V I -7 Phone Contractor's Name _P/4r'l ,Ppe%SgSVA)s License No. 2 _rsq - �3 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 ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dona ❑Type -of-ate�llork=Donee Well Destruction;, . 24 Well Diameter Sealing Material Itop 501 Depth F.ille"r Material (Below 50'V.1 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ `,REPA_IR/ADDITION DESTRUCTION El (No septic system permitted if public sewer is �e y ,, - 7 r. available within 200 feet.) ion nsfallatwill sive: Residence _Y Commercial— Other Number of living -units: -:/-:! umber of bedrooms Character of soil to a depth of 3 feet: ' "R Water table depth SEPTIC TANK @ "--C Type/Mfg Capacity_ No. Compartments .PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: `j Well Foundation-t"Property Line .3 LEACHING LINE No & Length of lines I-10 Total length/size fl FILTER BED r ❑ Distance_to nearest: Well /VCM&' Foundation �tD Property Line r SEEPAGE PITS ❑ Depth, Size4 Number SUMPS Distance to nearest:. Weil" A-E6rUE:� Foundation 10 r Property Line .t D15POSAL PONDS ❑ v hereby certify that (,have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and -regulations ofthe 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'pers6R-in 'such manner as to become subject to workman's compensation laws of California." Contractors 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.Cal'rfornia." The applicantmust call -for alt re ed -inspections. Complete drawingron reverse side. Signed t Title:Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by 1ate C p� Final Inspection by Date E ' ❑ 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. FEEI CK INFO AMOUNT DUE AMO�U'�NT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EN241REV.101631 v C(r�(- k. PP ' 'EH 1426 `N `T 1