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.. r. i. - APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. i r (Complete in Triplicate) i 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 E 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 i Local Health District.,,R Job Address 7/ !" 15�lfiff. City Lot Size PM F AsO 2747 Phone Owner's Name //� Address /11! License No. ��/ Phone Contractor's Name u . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION A, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL TLD. PROP. LINE ar FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing # ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth 4 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.6 Pi . State Work Done �/ d SD ,•Cj�(1 Well Destruction Well Diameter Sealing Materia atop 50') _ k Depth Filler Material iBel.vv 501 �� a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is x available within 200 feet.) Installation will serve: Residence— Commercial Other pq Number of living units: Number of bedrooms Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK ❑ Type/Mfg * Capacity No. Compartments h. F PKG. TREATMENT PLT. ❑ 1 Method of Disposal s 4 f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.,&Length of lines F` k Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑J Depth'- j -S ize Number t SUMPS ' ❑ Distance to nearest: Well Foundation� Property•Line t DISPOSAL PONDS ❑ i E �_ +` ti. 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 Locbl,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 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: ' rti that in the performance ofthe work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californi The applicant must- II 'al r vire ins S. Complete drawing on reverse si r . i Signed / Title: ie'-� W _ V Date: F -•- �" "" FOR DEPARTMENT US "ONLY /l�� Application Accepted by Date Area Pit or Grout Inspection by - Date Final Inspection by Date Ad '' nat Comments: Z` tk 466-6781 l7 Lodi 369 3621 C1Manteca -7104 0 ❑ Tracy i Appli ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +EH 13-24(REV.101m) k EH 1425 F �