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APPLICATION FOR PERMIT, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 17 (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.. - 9� � tQ �° ' Job Address _.._ �� 'Y� �• _ City Lot Size PM r Owner's Name AKidress V I I O&"'�6T— Phone } Contractor -6 . Address /`tBnse No. 6 c3 Phone r TYPE OF WELL/PUMP: U NEW WELLX, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOUP ❑ Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation Dia. of Well Casing Domestic/Private `Gravel Pack X Tracy Type of Casing Specifications I� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of-Grout t ❑ Irrigation _Approx Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 'We'll Destruction Oma`-`Well Diam'eter's' - �'—_-`Sealing Miienal stop f Depth Filler Material (Below.50')� ;TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Lf, DESTRUCTION ❑..1No'septic system permittedfif,public sewer is available within 200 feet.) Installation will serve: Residence_i Commercial— Other Number of living units; Number of bedrooms Character of soil to a depth of 3 feet Water table depth tSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments }PKG. TREATMENT PLT. F] ate.. Method of Disposal Distance to nearest: Well Foundation k Property Line I' ,rte tLEACHING LINE ❑ No. & Length of lines Total length/iiia FILTER BED ❑ Distance to nearest: Well Foundation Property Line' SEEPAGE PITS* ❑ Depth Size Number SUMPS Do.Distance to nearest: ..,Well — Foundation --, Property-Line r - t -rte s DISPOSAL PONDS ❑ 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. i' l 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.','Contractoes 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 Ca-fornia." The applicant ust call for allrequired in coons. Complete drawing o verse si e. Signed Title: Date:- =7 F - �.r. . r R D PA 1NENT USE ONLY t a 7 4 r Application-Accepted-by - - - -Date -.Area- Pit Area-Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LFk y\ oo ❑ Stk 466-6781 ❑ Lodi 369-3621 .❑ Manteca .823-7104 ❑ Tracy 835-6365 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 'RECEIVED BY DATE PERMIT NO. INFO CWW + EH 13-241REV.sia51 `" ` i EH 1426 ! ,.> 1 / ' ZL6 Ll o C