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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - - tComplete in Triplicate? 6 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 Sari 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 <1 �-� v�en, CityR54wa Lot Size PM i Owner's Name! -+ Address I- _ Phone Jeal 11b Contract.1 ' Addressf w - ` cense N T11Phone-7,-3 TYPE OF WELLIPUMP: �I4 x .N WELL ❑.�w r WELL REPLACEMENT ❑ DESTRUCTION ❑ t. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ # DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE Ir7YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` . ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private D Gravel Pack ElTracy Type of Casing I Specifications ❑,Public ❑ Other ❑ Delta Depth of Grout SealType of Grout ❑,Ircigation ( -Approx. Depth C1Eastern Surface Seal Installed by r r. "Repair Work Done ❑ Type of Pump H.P. State Work Done f We11 Destruction ❑ %Nell Diameter .. Sealing Material (top 501 ; Dgpth Filler Material (Below 501 �r ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Q DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.). Installation will serve: Residence_ Commercial Other Number of living units: �� Number bedrooms 1 Character of soil to a depth of 3 feet: `3'1y g. Wer table depth SEPTIC TANK ❑ Type/Mf Capacity '1&4 No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well �� Foundation Property Line 3 iYa.S LEACHING LINE 11 No. & Length of lines Total length/size J�_ FILTER BED ❑ Distance to nearest: Well Foundation ��` Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS E.I Distance to nearest: Well Foundation TProperty Line DISPOSAL PONDS ❑ 1 I hereby certify that I have p6pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ' rules and regulations of the'§an Joaquin Local Health District. Home owner or licensed agelt'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 riianner 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 Wperformeof the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California."The appli t st colt o iII r it ampi �rawing on arse side. Z- ell- Signed ` ,I Title: FOR DEPARTMENT USE ONL Application Accepted by q /� Date rea d Pit or Grout Inspection by I� Date Final Inspection'by Date 5 1416,7 fi Additional Comments: � r ❑ Stk 466-6781 ❑ 1.6di 369-3621 ❑ Manta 823-7104 ❑ Tracy 835-6385 1 !� Applicant- Return all copies,to: Enyironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT Nb. + EH 13-24 IREV.I R 5) EH 1126