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APPLICATION FOR PERMIT m SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`T ON AVE., STOCKTON, CA O, Telephone (209) 466-6781 O 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. ��J 7 Job Address A/',7 � A.S�,��y zA) City S//]/U. Lot Size PM Owner's Namely O�/z' Address Phone IMF/ Contractor/yAddress ?� iV- A:: � icense No.-* Phone_7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ArRE'fW/AUN STEM REPAIR JV 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,JODomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' C_ 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by i 1i Repair Work Done ❑ Type of Pump S& H.P. / State Work Done kT nw C/'QS/A16 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 A,mE ��zwx/ 44 49!*^�.e Depth Filler Material (Below 501 �l TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION I I DESTRUCTION I1 (No septic system permitted if public sewer is available within 2001feet.) , Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -- ter table depth SEPTIC TANK ❑ Type/Mfg Capac' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Le of lines Total length/size FILTER BED ❑ ance to nearest: Well Foundation Property Line SEEPAGE P I I Depth Size _ Number SU Ll 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: "1 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 al equire tions. Complete drawing on rev a s. _ Signed X I!J �'[LJ� Title: Date: 41 9 F!1_3RT ENT USE ONLY Application Accepted by Rate. L _Area Pit or Grout Inspectionby _ Date Final Inspection by Date le) Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. EH 13-24(REV.t/x5) 2s c"0 4-28 J EH 1