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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 W Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Jo in County Or 'nance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Heath tric� Job Address City PM 01 Owner's Name ifYlade�ss Z / / J &J:::' ""' '��"�'Q `e Phone '` � `�� Contractordress o&/ 4*lf'?—7 License No. 3�3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR i8" 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 ❑ JRfdustrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing (»/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 0?""----Approx. Depth ❑ Ea tern Surf ce Seal Installed by Of Repair Work DoneType of Pump H.P. State Work Done 14 Well Destruction ❑ Well Diameter Sealing Material (top 50') I^ Depth Filler Material (Below 501 U' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) h 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 FoundationProperty 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 n Joaquin Local Health District. Home owner or li ed agent's 'gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe n in such manne as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the Ilowing:"I certify at it the perfor nce of trtedray for w ich this permit is issued,I shall employ persons subject to workman's compensa- tion laws f California." The ap icant m or require Fisp Ing onrever side. Signed itle: r Date: /'/Al FOR DEPARTMENT USE ONLY ~`� UJ H Application Accepted by Date Area ��/J ��/ �� /,'- � Pit or Grout Inspection by Date Final Inspection by Data Hditional Comments: kStk 466-6781 ❑ Lodi 369-3621 11Manteca 823-7104 ❑ Tracy 835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. INFO CASH + EH 13-24(REV.1/65) EH 14-26 A--�