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F APPLICATION FOR PERMIT ,� q 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 the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for and the Rules and Regulations of the San Joaquin Local Health District. (` Job Address " �• P4 1� � ea to City Lod I, Lot ize © JX �f . PM ~ 4 Owner's Name 4 Address 345 R Phone /,6 11,ff,3 ,A, Contractor's Name _C��V_ v V V `^�nee No. � 'phdne � TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION E PUMP INSTALLATION V SYSTEM R P JIR ❑ /OTHEii ❑ _DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD/&— PROP. LINE !4 FOUNDATIONAGRICULTURE WELL OTHER OTHER WELL PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION S�PECIFICMOMrj/I C/ S ❑ Inf trial ❑ OpeK Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing omestic/Private V6ravel Pack ❑ Tracy Type of Casing ,� �� Specifications , lQ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal + Type of Grout ❑ Irrigation —Approx..Depth Eastern Surface Seal Installed by_ Repair Work Done ❑ Type of Pump U H.P. 2 State Work Done NS Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is "" r available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: !S Number of bedrooms Character of soil to:-a/depth of$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 Pbundatl6rf "Property Line —✓_tea 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,*44n 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 u call o all u' ins S. late drawing on,71Y r� side/.' Signed Title: y C_�L.I�Y rl� vL/[]t' Date:.L�/�LJ FOR EPARTMENT USE ONLY Application Accepted by Date Area Pito rou spection by Date Final Inspection by Data G �Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +EH 13-241REV.10/831 0 NJ� S EH 9428