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APPLICATION FOR PERMIT SAN JOAQUINrLOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAWFROM DATE ISSUED l (Complete in Triplicate) t<r: "; of Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or in the work herein described. This application is F made H 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 D' tBanc "f E^^- : 330r33 � # Job Address C1ty� �et� ize Lot's "� r PM Owner's Name F Address – Phone Contracto Address 79PZd ,44 i TYPE OF WELL/PUMP: License 0. F42-:§— Phone QeAv i NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ ' PUMP INSTALLATION'El SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK IQo;� SEWER LINES'*Z OTHER ' APO FOUNDATION DISPOSAL FLD. PROP. LINE AGRICULTURE WELL/d-J¢ OTHER WELL PITS/SUMPS G� INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTfON SPECIFICATIONS J Cl Industrial ❑ Open Bottom t❑ Manteca DiV of Well Excavation i] Domestic/Private Q Gravel Pack Dia. of Well Casing �v �fi 1 dTracy Type of Casing > ❑ Public Other ❑ Delta + Specifications Depth of Grout Seal Type of Grout ❑ Irrigation —�pprox. Depth: Eastern ° Repair Work Done ❑ Type of Pump Surface Seal Installed try ` H.P. State Work Done' Well Destruction x❑ Well Diameter�� iJ6y�j i� _. . _ Sealing Material (to 50'.) tet! o ma' �i Depth . . p Filler Material (Below 50') TYPE OF SEPT187WORK: NEW INSTALLATION ❑ - REPAIR/ADDITION ❑ DESTRUCTION fa (No septic system permitted if public sewer is Installation will serve: Residence available within 200 feet.) f Commercial Other 7^._,. ,Number of living units:' Number 'f bedrooms ` r f Character of soil to-a depth'of 3 feet: k SEPTIC-TANK -❑ Type/Mfg – Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments ; Distance to nearest: Well Foundation Method of Disposal Property Line LEACHING LINE - ❑ No. & Length of lines r FILTER BED - Total length/size q ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth .j. Size Number SUMPS *' ❑ Distance to nearest: Well Foundation DISPOSAL PONDS, p Property Line ' 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."Contractors hiring or sub-contracting signature certifies the following:"I certify thafin the performance of the work for which this ermit is issued, I shall employ tion laws of California." p .- � „, - - p y persons subject to workman's compensa- s w The applicant must call for all re,wired inspections. Complete drawing on reverse side. R 4 Signed , w Title: Q Date: / —/..; ter" ` FOR DEPARTMENT USE ONLY ' Ap icat�Accepted by -`a_J�S— a�? �y �,0 ate _ Area /, Pit or Grout Ins ion by ?/f Date ter. //�� Final Inspection by Date Additional Comments: l f �S ' d� { ❑ Stk 466-6781 ❑ Lodi 369-3621 # E3 Manteca 823-7104 - "❑ Tracy 835-6 385 4 / 3 Ap lica t= ReturnjIl c lest E viro ef�tai ealt Per_miVServices 1601 E. Hazelton Ave., P. . Box 2009, Stk., ` INFO .AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13.241REV.t/ss) EH 14-26