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APPLICATION FOR PERMIT Wo , 36 39 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. T made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an Local Health District. the application n U d Regulations of the San Joaquin Job Address City t Size Owner's NameA / PM Address �� / / Contractor 01 O' Phone TYPE OF WELL/PUMP: " ��Z r� NEW ELL ❑ License No.1 137 3 Phone I�O -�6 PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR — SEWER'LINES OTHER FOUNDATION AGRICULTURE WEL— DISPOSAL FLD. PROP. LINE INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS _ ❑ Ind 'al PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom —`-' omestic/Private ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other Type of Casing ❑ Irrigation ❑ Delta Depth of Grout Seal Specifications Repair Work Done —�pprox. Dept n ❑ E stern Surfa�e`Se'al Installed by Type of Grout TYPl i Pump H.P.--1� Well Destruction ❑ Well Diameter -------- State Work Done — Sealing Material;(top 50') Depth Filler Material (Below 5o') _J ee TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system ,l Installation will serve: Residence permitted if public sewer is r Commercial_ Other available within 200 feet.) Number of living units: Character of soil to a depth of 3 feet: of bedrooms SEPTIC TANK 0 Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity_ No. Compartments Distance to nearest: WellFoundation Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines ___ FILTER BED ❑ Distance to nearest: Total length/size Well Foundation ---_ �_ SEEPAGE PITS ❑ Depth SUMPS Size Property Line ❑ Distance to nearest: Well Number DISPOSAL PONDS ❑ Foundation_� property P rty Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,rules and regulatio an Joaquin Local Health District. Home own icensed agents ' nature certifies the following: ances, state laws, and employ a person in such manner s to become subject to workman's compensation laws of California."Contractor's hiring or sub-con "I certify that in the performance of the work for which this permit is issued, I shall not certifies t e following:"I c ify tha the perform ce oft tion laws f California." rk for which this permit is issued,I shall employ man's c signature The appli nt must f P Y Persons subject to workman's compensa- quired s c' Signed ing on reverse Title: A � Date: FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Date Area Additional Comments: Final Inspection by Date (4 11 Stk 466-6781 ❑ Lodi 369.3621 Applicant- Return all copies to: Environmental He❑altthaca Peermit/Serrvices41601 E❑Hazelton Tracy A;ve ., p gox 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK + EH 13.24(REV.L 95) 4. CASH RECEIVED BY DATE PERMIT`N0. EH 1426 J