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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 7 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 of No. 62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �J .. Job Address City al Lot Size / � ' PM Owner's Name —N�� 4%� f1Gi} Address 9i �7t f� o n�X 2-04??7 IF t Contractor �.-. �<,�° Address License No, Phone_ TYPE OF WELL/PUMP:. NEW WELL p WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E DISTA O NEAREST: SEPTIC TANK SEWER LINES_-- - DISPOSAL FLD.:. P- I�CNE � ' FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS # h INTENDED USE TYPE OF EM AREA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma Ia. tion Dia. of Well Casing .' ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications r Public ❑ Other ❑ Delta ,1..1. Deptfi of GFout Seal Type of'Grout I i Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by _ # Repair Work Do ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material (top 50') f � Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth fnl SEPTIC TANk ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i k ' Distance to nearest: Well Foundation Property Line pf LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size _ Number SUMPS 0 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. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the r whit s permit is issued, I shall not ~ employ any person in such manner as to become subject to workman's compensation laws of Califor ' r Contract res hiring sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, all employ persons subje t to workman's compensa- tion laws t511siar, Y Th est for.all required spectio Complete drawing o reverse side, 6 Title: ` Data: / r a FOR DEPARTMENT USE NLY pted by Area � � Date ection by ate / ma ns a tion by �.1P r/s.�� Additional Comments: ft* f6zze 6" _ /y7�?� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 OF-✓ Y70 p /t-j " I ,Applicant - Return call coRies to: Environmental He Ith Permit/Services 1601 E. Hazelton Ave., P.O. gox.2009, Stk., CA 95201 /7(�1 Z– dk e drl�as+ 5 U,caS [P�r e.T i1 s' s rn vh Loa x.et S 4a j FEE AMOUNT UE AMOUNT REMITTED % K INFO OMIT- RECEIVED BY DATE PERMIT NO. �y + EH 13"24IRpV.I//A5) / '3�_C3V U I EH 1446 -