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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 2 Telephone (209) 466-6781 J PERMIT EXPIRES 7 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. TMs 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 A/,Ze>LF AVie_A,, zC City. l n W� Lot Size PM Owner's Name A&c_ Address "' Phone 7 1 Contractor :, Address � License No,yf_,1._=. _Phone 2! 7 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 11-e Z! DISPOSAL FLD. PROP. LINE 1Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ^zNr-C .. Specifications of } ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout {A Irrigation --Approx. Depth Ll Eastern Surface Seal Installed by el /Repair Work Done ❑ Type of Pump H.P, %J State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 gr 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for all required ins ctions. Complete drawing on reverse side. Signed i 1- Title: If Ck'��•:. Date: FOR DEPARTMENT USE ONLY Application Accepted by _1447Date 17!�) LArea7N IPitor Grout Inspection by Date Final Inspection by � Date Ct Additional Comments: 1^! ` :r N ❑ Stk 466-6781 :Lodi 369-3621 ❑ Manteca 82 104 ❑ Tracy 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 CK H RECEIVED BY DATE RE IIT 0._ + EH 13-241REV.t%a51 EFF 14-28 iii/// ✓✓ �/ t "�U✓i/