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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '}a 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 l L11 //1 ]r � City /��2�TL'Z1-2Lot Size PM Owner's Name �� F1�6J�—� Address YG11�� /tel/�� "�"'� Phone c79%3_9_—c_ X M1 1 1� P—no 1C Address ,� �� Contractor License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ®. SYSTEM�REPAIR ❑ El'OaTHER DISTANCE TO NEAREST: SEPTIC TANK 1�00,� SEWER LINES Lim DISPOSAL FLD.IVQ PROP. LINE;23 FOUNDATION AGRICULTURE WELL �e—OTHER WELL�f—PITS/SUMPS AO'4-,)e� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KQomestic/Private Gravel Pack ElTracy Type of Casing Jr��— Specifications f"I Public Ll Other ❑ Delta Depth of Grout Seal ,"D Type of Grout I I Irrigation __.Approx. Depth ' t I Eastern Surface Seal Installed by - Repair Work Done X Type of Pump cSU/3M H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (l DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 I I Depth Size _ Number SUMPS Ll 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 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." 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 C The app�hca2n,2�tc;all,ft�orwl required inspections. omplete drawing,f� reverse side. Signed l Date: R DEPARTMENT USE ONLY Application Accepted by �� <� ./� Date 1 Area Pit or out nspection by J tem/� Final Inspection Inspection b ,v Date% Additional Comments:0�7/� y ��d ��`'f'�`o /D — ✓� 'F/ if6 G/W11_1/�c`�✓ "/'c'< ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M� 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 DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO /n / �+ ��L_ EH H + EH 13-24 IREV.I/H 5) /V S. 0e) L 0 • V 0 �33 �3 O y prf—� �� EH 14-2e !!! J