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i c. APPLICATION FOR PERMIT gz� t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sari 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. *2/ .; Zv Job Address _.//��_ t 4rR�./ _--/-�� Cityyza"yLot Size PM Owner's Name _ /V1'� e&/"'Y _ Address /lUl � �9fN lfJ� Phone v ^C/! f - Contractor 5 -5pddress o2O �i(�f License No. SSI Phone 5d/2f 7 ( 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 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )RDDomesiic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.-Approx. Depth I I Eastern S�rface Sea! Installed by / Repair Work Done ❑ Type of Pump ,rSl�� H,P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') xz2e3 /, Depth Filler Material (Below 501) / Com' TYPE OF SEPTIC WORK: NEW INSTALLATION (l REPAIR/ADDITION I ) DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other n Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth Q 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 i SEEPAGE PITS f I Depth Size _ Number " {� SUMPS 0 Distance to nearest: Well Foundation Property Line Q 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 l rules and regulations of the San Joaquin Local Health District. aws, and 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 appiica I requi ctions. Complete drawing on rev se side. SignedX ': itis: Date: *� X �QfS DEPARTMENT US NLY Application Accepted by DateArea ,:Kl l Pit or Grout Inspection by Date Final Inspection by ; Date Additional Comments: i ❑ 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 PERMIT NO. INFO CASH ♦.EH 13-241REV.1/A5) 3` S -oo EH 1426 /~�3�a