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2 Q APPLICATION FOR PERMIT J 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 San Joaquin Local Health District for a permit to construct and/or install the work herein 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 Regulations of the San Joaquin Local Health District. Job Address J /7 i fel• fcQ ' City L sNr ?,�,� Lot Size fet4e'-,lePM Owner's Name dt 'r, f ?f LE 140"& Address s4A/I IP Phone � CSF 4[ .LR"i Contractor ° d V ra�� I W Address License No. •L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK _: '� _ SEWER LINES 6�0," DISPOSAL FLD, PROP. LINE �� FOUNDATION AGRICULTURE WELL 'f OTHER WELL PITS/SUMPS ¢ye INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / 'r Dia. of Well Casing 46 Domestic/Private XGravel Pack ❑ Tracy Type of Casing Rj'z1;- Specifications Adv ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t�' Type of Grout.Zleoil ❑ Irrigation Approx, Depth ❑ Eastern Surface Seal.Installed by Y '1-e Repair Work Done ❑ Type of Pump — H.P. State Work Done_ Well Destruction ❑ Well Diameter `t Sealing Material (top 50') V S'6+ _ dip D pth Filler Material (Below 50'1 4r p(! TYPE OF SEPTIC WORK: F W INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noseptic system permitted if public sewer is 0 available within 200 feet.) J) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms '1 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 1 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 all re wired inspec ions. Complete drawing on reverse side. '° °` Signed X Title: ° Date: FOR DEPARTMENT USE ONLY Application Accepted by �'a ` Date -3 t Area y� � � Pit or Grout Inspection b �� ``� e �( ov�`t" Pe Y –tom Date Final Inspection by naeC Additional Comments: i l \@ ti , ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 'J891-71f ❑ Tracy 835-6385 S Qn Applicant- Return all copies to: Environmental Health Permit/Services 16015. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 a�1� INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE l9 RMIT NO. , ~,� ,.� + EH 13.24(REV.1/e5) 3 ' -7F 7- �J EH 14-28 /