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.t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.IT 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 I City r Lot Size PM Owner's Name Address M023 A), Phone tjt Contractor's Nam C! C:� License No'. 12 (a Phone TYPE OF WELL/PUMP: NEW WELL L3' WELL REPLACEMENT ❑ DESTRUCTION ❑ z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS P1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X� El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing vV ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation .--Approx. Depth ❑ Eastern Surface Seal Installed by > Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction L2 Well Diameter Sealing Materialltop 501 Depth Filler Material(Below•50') ~ TYPE OF SEPTIC WORK: NEW-INSTALL.ATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet_.) Installation will serve: Residence_` Commercial:'` Other— Number of living unitsr_/_L7Number•of bedrooms Character of soil to a depth of-3.feet: ' Water table depth SEPTIC TANKO'i Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ , ,_? Method of Disposal ' Distance to nearest: Will Foundation Property Line tEACHI_NG LINE-; jr_—�Nb. &'Length of lines --'�� ` ,. T?tal length/size FILTER BED El .Distance nearest: :,,Wen d _ Fo undation / d Property Line-- f� f SEEPAGE PITS ❑ Depth T �s�,. Size - >fF umber / / l ,y UMPS k"'bistance to nearest: W�MW Fo ndationE' /0/ Property Line 4rF DISPOSAL PONDS ❑ .' Thereby•certify that-l-have prepared-this-application and,that-the Work will'be done in accordance with San Joaquin county ordinances, state laws, and 'ules and regulations of the San Joaquin Local Health District:,, �':,..-X,� �-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 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- ' ibn laws of California." w The applicant must call r all required inspections. Complete drawing'on-'reverse side. Signed 7 Title•'3r r �' Date: FOR EPART NT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date �"�`' Additio hal Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. i ' ► �.