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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 ISSUED (Complete ii ,,TVOCate) r Application is hereby made to the San Joaquin Local Health District for a penriit to construct-and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sew_4e`ir No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. rf` pJ rr. Job Address lg (l �4Y� �, City Lot Size red PM J s4c7ht� ¢ Owner's Name t-D G C+ Address Phone Contractor A L 5-Lit I,C'' Address A License N,;)-7 S Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ — 7 41 0ACI 00 AP INSTALLATION C3 SYSTEM REPAIR ElOTHER 0��. a DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PRO?. E- t FOUNDATION AGRICULT OTHER WELL �PlT /SUS MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC_TiON SPCetF1CAIONS_ ❑ Industrial •❑ Open Bottom ❑ Manteca. —""-Dia. of Well Excavation -Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PackTr ca y Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ❑ Irrigation 1 Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0"'A Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK,.NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: ResidenceCommercial_ Other e Number of living units: �_ Number of bedroo s Character of soil to a depth of 3 feet: ��., $ Water table depth SEPTIC TANK ❑ Type/Mfg *- Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disppsal y Distance to nearest: Well �I bF�� Foundation - Property Line S'(2,_-.__ LEACHING LINE 2"No. & Length of lines dotal length/site FILTER BED ❑ Distance to nearest: Well lab+ Foundation�_.- Property Line 670t- SEEPAGE PITS 0-f Depthi 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 licgnsed 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 applicant must call for all requId inspections. Complete drawing on reverse side. Signed 4 , / Title: Date: doa e�'7 FOR DEP TMENT SE ONLY +. Application Accepted by Date � - Area Pit or Grout Inspection by Date Final Inspection by _,/, Date G r I _7f Additional Comments: ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354)M Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE.. AMOUNT.REMITTED CK RECEIVED 8Y flATE - PERMIT NO. - - INFO CASH { a + EH 13-24IREV.1/e5) - - '7 7 1�1� EH 14-M