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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 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 City 04A9& a- LotSize PM c Owner's Name Address Phone lC� Contractor Address 1_d License No.10 !,0 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j 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 CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom�.N El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing a.Specifications ❑ Public ❑ Other `� c[;J Delta. Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ~❑,Eastern` Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ' State Work Done Well Destruction ❑ Well Diameter ° Sealing Material Itop 50') Depth Filler Mate'JrO'(Below '1 ' TYPE OF SEPTIC WORK: NEW IPOTALLATIPN ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ' ,A available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: N er of bedrooms_ e Character of soil to a depth of 3 feet: _t Water table depth SEPTIC TANK ❑ Type/Mfg _ f` . Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest:. Well LL'' f Foundation Property Line i LEACHING LINE ANO. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Wellr Foundation� .�„-Property I_ine,�_ SEEPAGE PITS VIDepth — _�,. Size 3 �� _ Number SUMPS ❑ _Distance.to nearest: Well_lam -- 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 I rules and regulations of the San Joaquin Local Health District. N ,. Home owner or licensed agent's signature certifies the following: "h certify that in-the performance of the work for which this permit is issued, I shall not employ any person in such m'a`nner as to become subject.to workman's-compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I c�rtify 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 applica tcall foo 'ham red ins tions. Complete drawing on reverse side. r� Signed X�� Title: Date: /-e>—CS�"CSW FOR DEPARTMENT USE ONLY Application Accepted by I r/ Date Area I Pit or Grout Inspection by Date d r Final Inspection by Date 1 I � Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO ` + EH14-241REY.1i857 O k5q IS-45 � EH t4-28 O a - -