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AN APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin .-Local Health District. Job Address `S' C494&(/__[/ /?t Size PM Owner's Name 9Q& WJW77Z&Z6;ZW_ Address - A � Phone - f t Contractor's Name No. c�t/ Phone 4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL E- OTHER WELL PITS/SUMPS L"� I INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIO S �r t ❑��Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing e'Domestic/Private Cwt avel Pack ❑ Tracy Type of Casing' SCf6aSpecifications LJ Public 13 Other Ita Depth of Grout Sea! Type of Grout e-A ❑ Irrigation f4ff-Approx. Depth. -❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth-' Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer i available within 200 feet.) i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table-depthr.-- - --- - w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �" C :✓ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I ❑ Distance to nearest: Well Foundation Property Line._ SEEPAGE PITS 1 ❑ Depth Size Number �.SUMPS� - -- ❑ Distance'fo nearest:" ' Nell Foundation Property Line _ -- - DISPOSAL PONDS ❑ 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 ti rules and regulations of the San Joaquin Local Health bist7ict. 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." CORtractoes hiring or sub-contracting signature certifies the following:"I certify tAat 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 c or II require inspections. Complete drawing on revers ide. 1 F Signed Title:} r Date: F R DEPARTMENT USE ONVY Application Accepted b Date Area67 JO7,04, i Pit or Grout Inspection y Date Final Inspection by Date s Additional Comments: ❑ Stk 466-6781•• 0 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 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH IL + EH 13-24 IREV.101631 ~ ( � � f t 1 Z� EH 1426 � j t -