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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 San Joaquin Local Health District for a permit to construct and/or install ✓ ' i_f r' made in compliance with San Joaquin CountyOrdinance No. the work herein described. Thi application is 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address T ® " � il/ City Mot Size 29 L�C PM Owner's Name 91iJ .( dl )viii Lt _ Address Phone �5 Contractor d _�r,d[I� Address Phone License No.�Phone TYPE OF WELL/PUMP: INTEW WELL WELL REPLACEMENT)( DESTRUCTION Li PUMP INSTALLATION )( SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE Vao FOUNDATION AGRICULTURE WELL OTHER WELL ( f PITS/SUMPS ff 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 OiLOW i( �Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �"�' Type ype of Grout ❑ Irrigation � ac�rApprox. Depth ❑ Eastern Surface Seal Installed by p Repair Work Done ❑ Type of Pump jt p — H.P. / & State Work Done , ,1 Well Destruction ❑ Well Diameter gy Sealing Material (top 50') t One" W Depth /iD/ Filler Material (Below 50') It UJ- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -� Installation will serve: Residence_ Commercial— Other available within 200 feet.) Z Number of iiviF►g. its - -- 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,fines Total length/size P „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 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- tion laws of California." The applicant must call for l required inspec'ons. Complete drawing on reverse side. Signed Title: tr.�Cv Date: t OR DEPARTMENT USE ONLY Application Accepted biby Date w cArreea� '+L"�' Pit or Grout Inspection DateIt inal Inspection by erit� Date Additional Comments: � XStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ racy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DAMOUNT REMITTED INFO RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/e s) l/ /J4 EH 1426 <;Z-8` �� 1�� (