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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA 'Telephone {209} 466-6781 - PERMIT EXPIRES 7 YEAR FROM .DATE ISSUED ., ISIS., {Complete in Triplicate} 1 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 a made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and'Regulafions of 1116-San Joaquin ";Local Local Health District. r1 L�rz r r S Job Address City ® �'!Lot Size PM Owner's Name COUC relkCrV. Address 2= 711 /' Phone '/9 -� { �-G �ddress g� r� License No. �� Phone +/�,P/13_ Contractor --_.J� - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION .❑ l�� .1 PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS Q , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATlC�NS N �a ❑ Industrial F] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Dpvation_ Type of Casing L Specifications ❑ Domestic/Private Gravel Pack ❑ Tracy YP 9 �0 Ppa rkN p ❑ Public ��t�� ❑ Other ❑ Delta Depth of Grout Seal C7� Type of Grout t' V �Approx. Depth ❑ Eastern Surface Seal Installed by a-4� ❑ irrigation f'�I� P . Repair Work Done ❑ Type of Pump H.P. State Work Done _� r' (top Well Destruction ❑ Well Diameter Sealing Material 50'1 Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION ❑ DESTRUCT ~N ❑ (No septic system permitted if public sewer is available within 200 feet.) Ik Installation will serve: Residence_ Commerciale/Other Number of living units: Number of bedrooms .rr Water table depth 'I Character of soil to a depth of 3 feet: h I Capacity'" s - r� No. Compartments SEPTIC TANK ❑ Type/Mfg . PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size S FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distance to nearest: Well -Foundation Property Line DISPOSAL PONDS ❑ that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby-certify that I have prepared this application 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 >urcertifies 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- } t tion laws of California. ..... AX ca i for all quired inspections. Complete drawing on reverse side. d p ,e 4`i- )+K��` Title: R oS e. If7 RO �Are<OCo �liate: Ca Signed FOR DEPARTMENT USE ONLY q 1 Application Accepted by Date L Area Pit or Grout Inspection y Date Final inspection by Date Additional Comments:�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ t -7104 Tracy 5-6385 iii Applicant Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE kRMIT�NO. FEE - ASH INFO ]/ ..��y/ ' + EH 13-241REV.r.iHafVL� ��`' / EH 14-29 _ -