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APPLICATION FOR PERMIT �4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED t (Complete in Triplicate) Application is.heieby 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 weii/pump and the Rules and Regulations of the San Joaquin Local Health District- j ~ , �� h Lot Size PM Job Address City � ♦ r�wEhS Owner's Name J4�1 Tf ddress / Phone Contractor &ud Address JC 3- rl� License No.;Qa-��^ Phone 7 J�k TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:+SEPTIC TANK;— SEWER EINES 10V DISPOSAL FLMAWL POOP: LINE -^ "•�Y� - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIO Sf/ r f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing Domestic/Private ( Gravel Pack ❑ Tracy Type of Casing Specifications IPublic Cl Other. F1 Delta Depth of Grout Seal k Type of Grout . I ) Irrigation _Approx. Depth- " Eastern Surface Seal Installed by G/NPY _ Repair Work Done ❑ Type of Pump4 H.P- tate Work Do e — Well Destruction Well Diamet/e)r. Sealing Material (top 50') ( 0 Depth Filler Material I Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is 11 available within 200 feet.) Installation will serve: Residence_' Commercial_ Other Number of living units: Number of bedrooms I I Character of soil to a depth of 3 feet: Water table depth"" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of p Sal. O Distance to nearest: Well Foundation Property Line f U O LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ��`I<'` .°t!S"{`yrrr•r^'_I, ' Y� SEEPAGE PITS I I Depth 1: Size Number_ ' L_I'D&Uncd}}to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t. 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: "1 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." 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,l shall employ persons subject to workman's compensa- tion laws of California." 1 The applican ust c I for EI req a inspections. Complete drawing on remirse nside- Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date ' Area_- Pit or Grout Inspection by Data 17- inal action by Date fl ` 4,7 Additional Comments: - 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-710e ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520T" ' FEE AMOUNT DUE } AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO- INFO CASH \�L +-5+4 C//cam{ 13-24(REV.t i k 51 . S i EH 14-26