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I r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTN psVj 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 rConitfactor Health District. �,,IG I f Address4q , T Cit of Size 15 PM I 187 r's Name 1 p e� ��4nsddress� l ! C7�!t F 1� Ci�, �tL� Phone � �11 L Address ' License No. Phone_ r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I � PUMP INS CATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO D. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type o`Casing Specifications (•1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' I I Irrigation �.Approx, Depth I I Ea� stern' -! Surface Seal Installed by _ Repair Work Don Type of Pump # H.P. ' State Work Done _ 7 Well Des Ion ❑ Well Diameter Sealing Material (top 50') (�} Depth Filler Material (Below 501 —_ \ TYPE OF SEPTIC WORK: NEW INSTALLATION I Iw REPAIR/ADDITION INo septic system permitted if public sewer is _R/ADDITION I I ,DESTRUCTION I available within 200 feet.) I Installation will serve: Residence_ Commercial__Other- Number of living units: Number of bedrooms n Character of soil to a depth of 3 feet: Water table depth (y U SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r 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 SEEPAGE PITS i I Depth Slze ` _ Number SUMPS D 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 i 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 applicant m st call for all required inspections. Complete drawing on reverse side. / + Signed X . 5'1 Title: Q �PAY Date: I FOR DEPARTMENT USE fJNLY I Application Accepted by 44.6. Date Area v Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: f ❑ 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 CK RECEIVED BY DATE PERMIT'NO. EH 13-24 a EH 14-25(REV. s7 n V V �S D IJ �ys