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Z}3w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 306 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A ('Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hwein-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 R6¢utations of the San'Joaquin Local Health District. Job Address ^Z6 4 7 A4AV_1� �"�" City sm_ Lot Size PM Owner's Name 7//�///�S Vo ��ddress 99W_ Phone Contractor dress fy® �� License No. Phone J,1 -;� -- 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 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other fl Delta Depth of Grout Seal Type of Grout _. I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.:, State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 �-(L r /�A1::7,777A,4_ .Depth ___ _._ _ __Filter Material (Below 501- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercia!._ 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 I LEACHING LINE ❑ No. & Length of lines- Total length/size FILTER BED ❑ Distance to nearest: ;Well Foundation Property Line SEEPAGE PITS i I depth_ Size _ Number SUMPS LI Distance Ito 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 regulatiofls of the San-Joaquirr4oea6 Health District: ` Home owner or licensed agent's Signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such'manhe'f 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- iionlaws-of Theapplicant or II re tions. Complete drawing on reverse side. 1 polo) Signed X� Title: y - Date: X5A 0 If FO EPAR E SE 04Y Application Accepted by Date rr a Pit or Grout Inspection by Date Final Inspection by �4/l Date Additional Comments: 41, ' ❑ 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 CK RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.i i n a) N L EH 14-26