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' APPLICATION FOR PERMIT i SAN JOAQUIN•ILOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F F B PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_NVIROMENTAL HEALTH ' (Complete in Triplicate) FERMIT/SERVICES 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. Jab Address l � � •-Q_,, __ City Lot Size PM Owner's Name Lo I, V r '�i ct �A40L Address ils 44 Phone •t- � % ` R � � Contractor ✓ Address .License No/ r� TYPE OF WELL/PUMP: NEW WELL ❑ `W �� ELL REPLACEMENT ❑ DEQ STRUCTION�, _t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 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 i.- pia. of Well Excavation ' Dia. of Well Casing �} ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f' Type of Casing I Specifications C> ❑ Public �❑ Other 1-1 Delta �.:=Depth of Grout Seal Type of Grout � ❑ Irrigation ---Approx. Depth ❑ Eastern j Surface Seal Installed by '. Repair Work Done ❑ jType of Pump H.P. _ C Well Destruction 5( (Well Diameter f� �` Sealing Material (top 501 ;Depth G Filler Material (Below 501 TYPE OF SEPTIC WORK:; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑�,(No septic system permitted if public sewer is .� �evailable within 200 feet.) R Installation will serve: Residence— Commercial i Other Number of living units: I Number of bedrooms, Character of soil to a depthof-3"feet: _ �"1.. `� Water table depth —`SEPTIC TANK Type/Mfg r`'. Capacity t_. No. Compartments j PKG. TREATMENT PLT. ❑ J (` Method of Disposal 1 Distance to nearest: F Well_LLFoundation property Line i LEACHING LINE E-1 No. & Length of lines --� 9 Total:length/size FILTER BED Distance to nearest: Well ?_ Foundation Property yLine SEEPAGE PITS ❑ Depth Size ; Number SUMPS TI.. Distance to nearest: . ' Well ? Foundation ' Property Line DISPOSAL PONDS F-1%�` ? ' 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. i i Home owner or licensed agent's signature certifies the following: "llcertify that in the performance of the work for which this permit is issued, I shalt not employ any person 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 California." �r The applicant st all fo� all required inspections. Complete drawing on r verse side. Signed Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0Z Pit or Grout Inspection by Date Final Inspection by Date/,2--9Ta 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 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE( (P�ERMIJT`'NO. �1 + EH 1&24 IflEV.7/B 57 .. ._ _ ' EH 1426