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APPLICATION FOR PERMIT SAN JOAQUIN LOCAs. HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA r � Telephone (209) 466-6781 "1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T .(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 2$AM L0 I City 08h)k)Lot Size PAAy n� I Owner's Name L Address 0 L tWE Phone t I Contractor's Name aft&=- II"�u�A&&License No. y� 1 Phone 49 4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION E] 1 PUMP INSTALLATIO / SYSTEM RE7PAI� '❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v K Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing E Specifications / ❑ Public Other ❑ Delta Depth of Grout Seal 7s 0 I T e of Grout ❑ Irrigation �A I ` g ---Approx. Dept ❑ Eastern Surface Seal Installedv' L Repair Work Done ❑ Type of Pump H.P. I IZ State Work Done r r Well Destruction ❑ Well Diameter G f Sealing Material (top 501 Depth Filler Material (Below 501 . i ,,,t.1TYPE OF SEPTIC WORK: NEW (INSTALLATION ❑ „REPAIR/ADDITION.❑ .•DESTRUCTION ❑ (No septic system permitted if.putilic sewer is -�V ..M�.p,y.. 7.t;.,,.��. ..availatiiewiffiin200feet:l_.. .. _e ,. Installation will serve: Residence= Commercial I Other rr Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth }r SEPTIC TANK ❑ Type/Mfg Capacity— ' No. Compartments PKG. TREATMENT PLT. ❑ ; `” ^�— L� Method of Disposal Distance to nearest: Well Foundation : Property Line t LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f Property Line I � n SEEPAGE PITS ❑• Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ yam, 1 1 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 oftalifornia."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 st call for all required in tions. C to drawing on reverse side. Signed Title:_ Date: i yu. f FOR DEPARTMENT USE ONL1L> ` Application Accepted by f Date —�Area._Date FiPit or Grout Inspection by nal Inspection by ate f b� =' 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 AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT"No. INFO CASH } +EH73-241REV.101831 W:Sti 111 W EH 14-28