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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON 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. TMs application is f made in gompliance 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 51 ;e �� City p—'K7o A Lot Size PM y Nay�Se At A Al a 6Rnl S�yaa2��11 7�, Owner's Nam Address Phone Ci6Rw'IAAI�� qr C J<7� ,i'kd0X aA� 6�f!/� ` Cont/actor Address .2� License No. Phone_ 3/-3.2 d i TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 4 SYSTEM REPAIR ❑ `/O�TTHHE�EI) ❑ �� DISTANCE TO NEAREST: SEPTIC TANK _tZo.7- SEWER LINES �� DISPOSAL FLD.L�dG- POOP. LINE FOUNDATION /aof — AGRICULTURE WELL OTHER WELL —r' PITS/SUMPS Da INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �// y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casin Specifications Domestic/Private Gravel Pack ❑ Tracy Type of Casing P �� T El Public ..11❑ Otrer El Delta Depth of Grout Seal O Type of Grout El Irrigation oC100- 4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump v6 H.P. Sta e Work Done Well Destruction ❑ . Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .T, available within 200 feet.) 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 SEPTIC TANK ❑'- Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ I. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 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 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:"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 applica all r ctions. Complete drawing on rev rse side. S` ��1/TIV 110— O S Signed X Title: Date: FOR DEPAR MENT USE ONLY Application Accepted by Y21_ Date4/ f Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 E4 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 CASH RECEIVED BY DATE PERMIT NO. INFO + EH1324 MEV.I/e sl EH 14-26