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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (} 2- 1601 E. HAZE T ON 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. This application is made in compliance with San Joaquin County Ordinance No.54.4 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City /"rL-C Lot Size PM Owner's Name CS t. Address `�`�� _- �� QS3S3 Phone Contractor �t``�✓? Address �� 06"_ d INV License No.&j/e 2a __Phone 63 TYPE OF WELL/PUMP: NEW WELLXI Yu�olls WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O— DISTANCE TO NEAREST: SEPTIC TANK IVA SEWER LINES C?a DISPOSAL FLD. PROP. LINE FOUNDATION S AGRICULTURE WELL A/A OTHER WELL A/� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F3' Dia. of Well Casing ❑ Domestic/Private Grave! Pack Tracy Type of Casing p�r'r G Specifications F] Public Cl Other C I Delta Depth of Grout Seal ! TT.yp�e�of Grout ._- M I I Irrigation __-Approx. Depth l I Eastern Surface Seal Installed by 06)"�_�' '� cx`)i Repair Work Done ❑ Type of Pump H,P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feeL1 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. ❑ Method of Disposal - Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 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. Home owner or licensed agent's signature certifies the following: "!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 applicant Tust call for allr uired inspections. Complete drawing on reverse side. ` ~ pJ 6GC)`0 Date: Signed XTitle: s ) � • .�c�.—J11 '� fes- . R D PA TMENT USE ONLY Application Accepted by Date d r Are Pit or Grout Inspection by ate t final Inspection by Date/� Additional Comments: El Stk 466-6781 ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO CASH ♦.EH 13-241REV.t/H51 3_5 3,5 A f eq )0_1341 j q-c�Szxg- .y.,..! ,fH 14.29