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I APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 2 Telephone R f 091 468-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address1 64 7/Vn /0' Cit Lot Size _.�y -,C,,e 5 PM Owner's Name Address t Phone Y* E { ' p /r Contract Address +c 7 [.f License N n 2_ Phone —S_1 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 1 CONSTRUCTION SPECIFICATIONS l ❑ Industrial Q Ope6 Bottom, El Manteca Dia. of Well Excavation j Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack }f ❑ Tracy Type of Casing Specifications f"i Public 171 Other C.❑ pelta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth t )'-Eastern T Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. i State Work Done_ ! Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth 'ler Material (Below 501 DESTRUCTI TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR DDITIO ON i I fNo septic system permitted if public sewer is I ' available within 200 feet.) Installation will serve: Res'dence Commercial_ Other Number of living units: Number o � shy Character of soil to a depth of 3 feet: �" Water table depth (1 0 SEPTIC TANK ❑ Type/Mfg Capacity . No. Compartments PKG. TREATMENT PLT. ❑ _ ,_ .. Method of Disposal.. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len th of_fines rf' g _ Total'Iength/size FILTER BED ❑ Distance to nearest: Well Foundation.. _r Property Line _ 1 SEEPAGE PITS .Depth -) Size bl m'be� { SUMPS � Ll Distance to nearest: Well f=oundation A _ 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 Dl�trict. e—� Home owner or licensed agent's signature certifies the following: "1 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 m tali fora 'ed inspections. Complete drawing on reverse id� Signed X Title: r Date: 4 qtr F.OR DEP MENT USE ONLY �r Application Accepted by Date �J Area Pit.A/Grout Inspection by Date Final Inspection by T r Datec) Additional Comments: ✓J ❑ 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED Ely DATE PERMIT NO. + EH 13-24(REV.rir+sl 1 EH 14-2e o O