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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE� p ISSUED`r y (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -06 5r l_ L � �� P_ City D mot Size PM r C Owner's Name `` ll4l�C'C',1�_p✓ Address Phone Contractor � Address - . �r�/d w[�License No. C7 Phone TYPE OF WELL/PUMP: NEW WELL D WELL'•REPLACEMENT,❑. DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR '\. BOTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLO. M "' PfiOP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial '[D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing PC '❑ Gravel Pack ❑ Tracy Type of Casing - A Specifications F] Public n Other f-] Delta Depth of Grout Seal Type of Grout _ I I Irrigation _ _Approx. Depth I 1 Eastern Surface Seal Installed by ` Repair Work Donei•Type-of Pump H.P. 7�i, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:' NEW INSTALLATION I] REPAIRYADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 7 available within 200 feet.) Installation will serve: Residence— Commercial_ Other l Number of living units: Number of bedrooms Character of soil to a depth of'3 feet: Water table depth f SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments 1 t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING'LINE Cl No. & Length of lines Total length/size FILTER BED J 0 1Distance to nearest: Well Foundation Property Line SEEPAGE.PITS ; I;e Deptfi_-"''j �- Size _ Number SUMPS .LI 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 terson 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 applic ' st call for all requ- inspec' s. C late drawing on se side. Signed X Title: Date: a �� FO TMENT USE ONLY Application Accepted by /�' / i F� �•_•._ pate !-' _ Area�w Pit or Grout inspection by ' -.Date Final Inspection by Date Additional Comments:', ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑,Tracy"'�L 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 J 1 ` 4 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE I ERMIT NO. r + EH 14-26IREV.I/H 51 .�S..f70 /_ f I—P(� ""�.�/�/S