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APPLICATION FOR PERMIT CJT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 55 - ; Telephone (209) 466-6781 � PERMIT EXPIRES ES 7 YEAR FROM DATE ISSUED f al (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. - s 'Jrce�-0 a'-U'-I?� P Job Add re Ci0—�X��ot Size M -%I r Owner's ' -} Q Address Phone �3� / -s r r ,Contr ar S u .License-N one 7 TYPE OF WELL/PUMP: NE�Add�res.s L �V .WELL REPLACEMENT ❑d DESTRUCTION ❑ PUMP INSTALLATION ❑- SYSTEfiA-REPAIR"❑ ;" J-'OTHER"❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES �' � DISPOSAL FLD. PROP. LINE i FOUNDATION`, 3- " `( '/AGRICULTURE WELL OTHER WELL—! PITS/SUMPS 1 INTENDED USE TYPE OF WELL PAOBLEMAREA CONSTRUCTION SPECIFICATIONS. { ❑_ Industrial :5 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ' 8'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r Ll Public Specifications ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout PATrgation4pprox. D L2Eastern Surface Seal Installed by i Repair Work Done LJType of Pump. H.P. State Work Done Cc1 111 Well Destruction El Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') rn TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ A EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) w Installation will serve: Residence._ Commercial Other '' Number of living units: Number of bedrooms ' rn Character of soil to a depth of 3 feet: r Water table depth , r SEPTIC TANK ❑ Type/Mfg. Capacity � /No. Compartments PKG. TREATMENT PLT. ❑ "Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line JJ 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 rules and regulations of the San Joaquin Local Health District. laws, and Homo 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 1 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 compa re tion laws of C r rnia." l The applic m si call for all require in c ns. C late drawing 79i e side. Signed Title: Date FOR DEPARTMENT USE ONLY Application Accepted by �� C Date Area Pit or G21 rout Inspection by Date Final Inspection by Date Additional Comments: �r.67i i .� ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy- 835-6385 ';4pplicant_- Return,all.copies.to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ---A�t.T-DUE AMOUNT REMFTTED 1CK 4 INFO ' CASH RECEIVED BYa DATE PERMIT NO. �� +� n + EH i3-241REY:1%B5) EH 14-285 S-7 t? i