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APPLICATION FOR PERMIT ' o SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 7-'s, Ll L9 City Lot Size PM "� rn19 Owner's Name Address � � pj,�/ Phone C��- Cr Contractor 1 % Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION $�. SYSTEM REPAIR ❑ OT R ❑ DISTANCE TO NEAREST: SEPTIC TANK _-�� SEWER LINES 00 't_ r y -. �� r �q,��,, DISPOSAL FLD.NU �PROP. LINE�LX�' FOUNDATION -100 AGRICULTURE WELL Nkk r- THER WELL IND L2 PITS/SUMPS I0Q16IC INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ka-mestic/Private V-Gravel Pack ❑ Tracy Type of Casing 5 , Specifications f-I Public f i Other f-7 Delta Depth of Grout Seal i aJ Type of Grout 1 1 Irrigation ._- Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done X Type of Pump :�!W H.P. _.._ >3 State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material (top 501 �1 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I'I 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 Ca acit ~ P y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/sizet FILTER BED U Distance to nearest: Well Foundation Property Line �I SEEPAGE PITS I 1 Depth _ Size Number Il SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 Diktrict. Home owner or licensed agent's signature certifies the following: "E 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 Califor�� The applicant trfi call for all required inspections. Complete drawing# reverse side. Signed X /l% IT�t®: Date: y R DEPARTMENT USE ONLY Application Accepted by s..r Date Area Pit or out nspection by te�l6 Finall Inspection b Date�� Additional Comments: Oe/ dc�G�ic{o /D — �� lE� 4/141, CI ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant a 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 0 K D RECEIVED BY DATE PERMIT'NO- + EH 14-26 33 riH 51 IO S. QV [05' UV rf33 -3~PI P�'— r& EH N-26