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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. yyqM�r jC ti Jab Address ` 2 City Lot Size PM �52a 5 j Owner's Name Address 3� Phone v li Contractor - -w - -Address=_ L161Licenge No, �.r Phoned I-n E TYPE OF WELL/PUMP: NEW WELL_).K,7 WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ._. SEWER LINES ,f- DISPOSAL FLD._LrL PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO � S p/ ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domes'tic/ LJ Gravel Pack L1 Tracy Type of Casing Specifications i ❑ Publics ❑ Other ❑ Delta Depth of Grout Seal � � Type of Grout I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. State Work Done _ .i Well Destruction ❑ Well Diamete Sealing Material Depth le Filler Materi Blow 50') TYPE OF;SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION 1 I INo septic system permitted if public sewer is C SCJ available within 200 feet.) F Installation will serve: Residence_ Commercial-___ Other Q Number of living units: Number of bedrooms Character ottisoil to a depth of 3 feet: _ Water.table depth - I .� v r SEPTIC TANK ❑. Type/Mfg pacity NoCom�'partments { PKG. TREATMENT PLT. ❑ Method of Disposal T Distance to nearest: Well;��Foundation Property Line : LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line- SEEPAGE ine SEEPAGE PITS l I Depth Size _ Number i SUMPS ' ❑ Distance to arest: Well Foundation Property Llne 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. i° '^ ,- ' t - -y.,�;t 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.amploy persons subject to workman's compensa- tion laws of California, t The applicant m A�fo, equird insaillictdms. Complete drawing on reverse side - _,r ,. • ' ;`.s='r' a /� Signed X Title: 1I rb t: Date: fQ iA400V FOR DEPARTMENT USE ONLY Application Accepted by Date �r_b^ ` -IAraa Pit or Grout Inspection by ate k}��'I�j! Final Inspection by �1 ate / I 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 A FEE F INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY 1 DATE a 4 PERM17'N+O4 + EH13.24 iREV.1/nal ♦ ,/'/j�� .` _ � ` ,1� �+� EH 14-26 v