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APPLICATION FOR PERMIT SAN JOAO.ULN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES Y1 YEAR FROM DATE ISSUED v j (Complete in Triplicate) t 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.649 for sewage or No. 1862 for well/pump and'the Rules and Regulations of the San Joaquin Local Health District.' t Job Address �� h� r l)e' R0,1d apt 8i&W-`5 City Lot Size PM Owner's Name_ A` 6 x'105 Address N t W` �O "��o°U Phone L47ff ! gs Contracto i e` 6nsQ1'6>V-f_S Address 52� GAves-on License No. Phone TYPE OF WELL/PUMP: NEW wELLW WELL REPLACEMENT ❑ DESTRUCTION 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ 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 3 Sealing Material Itop 50'1 �ev )l k/51 4f Depth 35-50 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) k 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 I SEPTIC TANK ❑ Type/Mfg Capacity -No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 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. I 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 became 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 Myst call for all required inspections. Complete drawing on reverse side. Signed X _]JA'1 k Title: re-QDate: FOR DEPARTMENT USE ONLY Application Accepted by Date r � Area . t J Pit or Grout Inspection by Date Final Inspection by f / Date �7 Additional Comments: fel/ l sG5 El Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 racy 836-5385 5 I 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 A# RECEIVED BY DATE PERMIVNO. INFO + EH13-24(REV.i/rs 5 } EH 14.28