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Y R, Ha APPLICATION FOR PERMIT t�"Cr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to the San aquin cal 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 .54`f!forsewage or r+Nsunp an the Rules and Regulations of the San Joaquin Local Health District. LAC_+ t 179-,Q7�. Job Address 1�67uY-� f�'F - �St'�ami S Lot Size PM Owner's Name _ O lI N � ��2 Address S N Phone 67f IS' Contractor 1 7-0Z a MY/23ze License No.�/Z7-66_3Phone WO—044; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER;W- DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL �'—�j�rf� 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS oeeP ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �s W rr L l'l Public L] Other n Delta Depth of Grout Seal T — I I Irrigation Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P, State Work Done — 1 Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material [Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is j available within 200 feet.) i Installation will serve: Residence— Commercial_ Other i Number of living units: Number of bedrooms t 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 `•� 1 Distance to nearest: Well Foundation Property Line LEACHING LINE length/size Cl No. & Length of lines g FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS t I Depth Size _ Number SUMPS LI 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: "I certify that in the performance of the work for which this permit is issued, l shall not -� employ any person in such manner as to become subject to workman's compensation laws of California." Contractors airing 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 st call for all eq d inspections. Complete drawing on reverse side. < Signed X Title: Date: Le FOR DEPARTMENT USE ONLY AApplication Accepted b i Date Area pP p Y IV Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments r VKi(-e "` W Oo� 168 RJ e 6 (4 04 WPY l ❑ Stk 466-6781 ❑ Lodi 369-3621 b Manteca 823-7 04 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CAJH RECEIVED BY DATE PERMIT NO. INFO a.EH 13-24(REV.Tina! EH 14-26 �-