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APPLICATION FOR PERMIT 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. This application 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. 7 PP anon is � quin Job Address City Lot Size C Owner's NameA-1WA 11 PM Address �i�m �/ �` Phone l 1rS— 3 67 2- Contractor /C C!"W]y ��j�^S WOOCWX14106; TYPE OF WELL/PUMP: Address Ox /7� NEW WELL License No. 7 a i___'�f S Phone 5��rj WELL REPLACEMENT ❑ PUMP INSTALLATION DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANKOTHER El REPAIR El10--` SEWER LINES _ DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE"��O INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS _ ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom $ilfD ❑ Man Dia. of Well Excavation i U omestic/Private Gravel Pack ❑ Tracy /� Dia. of Well Casing El Public Type of Casing__l" ❑ Other ❑ Delta Specifications ❑ Irrigation Depth of Grout Seal �'Z y Repair Work Done ❑ —APProx. Depth Eastern SuSeal Installed b �+, Type of Grout Type of Pump H.P. rfac y A-, 7R r ? Well Destruction ❑ Well Diameter / _ Sealing Material Ito rop-) Mate Work Done_ Depth (/7 p TYPE OF SEPTIC WORK: Filler Material NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted Installation will serve: Residence_ available within 200 feet.) �f public sewer is Com Number of living units: Commercial_ Other Character of soil to a depth of 3 eember of bedrooms SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity_____ No. Compartments Distance to nearest: Well Method of Disposal Foundation Property P rty Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS El Depth SUMPS Size ❑ Distance to nearest: Well Number DISPOSAL PONDS Foundation ❑ -- —_ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin co rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: q county ordinances, state laws, and employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting "I certify that in the performance of the work for which this permit is issued, I shall not signature certifies the following- k "I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." P Y persons subject to workman's ompensa- A�� The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: 01 Date: Q Application Accepted by R ARTMENT USE ONLY Pit or Grout Inspection by ��(� FArea , Date ib –� Date Linal Inspection by (/ Additional Comments: Date " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazel on Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED C + EH 13-24(REV. sl RECEIVED BY O DATE PERMIT'NEH 1428 J. D� /dS - /6f7 O.