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APPLICATION FOR PERMIT ". SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL-1 ON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED iCornplete 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. IE62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ` s City Loi Size ��" l PM Owner's Name CUs �cl�J R Address`�c�7 D �� / c�„gRrf _ Phone Con'l:rac�RT )f;ZAMP¢�PPky Address License No. [O� n� L Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 420A)C- SEWER LINES 6010r— DISPOSAL FLD�. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLA nk�PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing S22i� Specifications F] Public C1 Other ❑-Delta Depth of Grout Seal r� , Type of GroutikLYMIJI ❑ Irrigation ---Approx. Depth ❑ Eastern ,Surface Seal Installed by Repair Work Done ❑ Type of Pump F6 H.P. l - State Work D ne Well Destruction C1Well Diameter Sealing Material (t p 50') Depth Filler Material{Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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.`O ^� V � w d Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Prop".Line F SEEPAGE PITS }'El 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 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 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 applica st callior all required inspections. Completed ing on reverse side. ! =--� Signed isle: � T_/_L�� Date: r 'FO EPARTMENT USE ONLY Application Accepted by l Date!'r` `�Ut� Area Q / { �F Pit o rouf pectian by Date ( t�� Final Inspection by 0 p Date • f Additional Comments: ❑ Stk 466-6781 0-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ------------- FEE �. '-INFO �'AMOWNT,-0UE�. —AMOUNT.-REMITTED CASH —RECEIVED BY -t -DATE "PERMIT'NO.'' + EH 1 -24(REV.-r/a57 IDS=O� �+�3� II–�U--�To i'yq� i EH 14-29 r