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APPLICATION FOR PERMIT a SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E: HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' ` fi (Complete in Tripllcafe) a . E..F . fLo-7 - br }CQ�fPT.�I� 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. 1852 for well/pump and the Ryles and Regulations of the San.Joaquin 1 Local Health District. - Job Address City 6 ' ' `Lot Size 1_/ PM Owner's Name ^� Address - = Phorie ��"� i Contrac Address License Na'.f Phone 3 - TYPE OF WELL/PUMP: NEW WELL Elj W LL REPLACEMENT ❑... -� T DESTRUCTION ❑ PUMP INSTALLATIONS ❑ SYSTEM REPAIR IDOTHER El DISTANCE TO NEARS 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 ❑rManteca L; If Dia.of Well Excavation Dia. of Well Casing 1—❑ Domestic/Private 11 Gravel Pack a�Tracy �"�- FType of Casing Specifications ❑)Public ❑ Other ❑-.Delta)' J S Depth of Grout Seal Type of Grout \, ❑ Irrigation --Approx. Depth ❑ Eastern } Sur ace Seal Installed,by -\A;- Repair Work Done [IType of Pump H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material-(top.5p`1s 1 } Depth Filler, Material,(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP_A_IR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is # �^available within 200 feet.) Installation will serve: Residence�� Commercial_ Other i Number of living units: Number of bedfoo sSr Character of soil to a depth of 3 feet: CN{ _Water table depth �f SEPTIC TANK ❑ Type/Mfg capacity No. Compartments PKG. TREATMENT PLT. ❑ r t Method of Disposal f Distance to nearest: Well I- T, Foundation Property Line LEACHING LINE 0 No. & Length of lines 7 )C.,...�, Total length/size f'6 FILTER BED ❑ Distance to nearest: Well Foundation Or Property Line �Cs� 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 cert' i s 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 tc bec subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in t e rfo mance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion$laws of California." The'applicant t for r ui d i s ns. Complete drawing on reverse side. SignedTitle: t+, Date: { FOR DEP RTMENT USE ONLY { Application Accepted by` � Date -" - Area Pit or Grout Inspection by 'V Date Final Inspection by Date 1 .V Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 KManteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environments Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY .DATE PERMIT'NO. r INFO CA _ ov } + EH 13-24(REV.v/H5) .. S- EH ` EH 1426