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Pw APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT (� 1601 E. HAZE T ON AVE., STOCKTON, CA p� +' 1 '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. y + , Job Address" o� ll iCity ` Lot Size PM Owner's Name� ;CAddress .�! `7"`(�> S, AUfPhone" Rai 4Contractor Address i f f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER '❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER CINES" -DISPOSAL FLD. PROP. LINE %M FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS E i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s 17 Industrial % ❑ Open Bottom ❑ Manteca +� ." Dia. of Well Excavation ' Dia. of Weil Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ..+`Type of Casing Specifications ❑ Public ❑ Other' V.❑ Delta Depth of Grout Seal Type of"Grout r `\ ❑ Irrigation Approx.fDepth 1.0Eastern :` a Surface Seal"Installed by: Repair Work Done ❑ Type of Pump *° H,P, 'State Work Done_ Well Destruction ❑- Well Diameter- Sealing Material (top.50')._ Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ;DESTRUCTION (No septic system permitted if public sewer is _ t savailable within 200 feet.), Installation will serve: Residence{ Commercial_ Other }, Number of living units: Number of bedrooms a „ Character of soil to a depth of 3 feet-, Water tableldepth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal t 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 P SUMPS l ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ I 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 Joaquiri 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 California.". The applican ust call for Zallqu" d inspections. Complete drawing on reverse side. • s� / Signed Title:MNP1111— Date: 3-0 FOR D ARTMENT USE ONLY Application Accepted by' Date �� " 17 Area a Pit or Grout Inspection by ),I _ Date Final lnspectio Date Ad Itional Comments: r 'WeToabzw�ete, Stk 466-6781 ❑ Lodi 369-3621 ULI Manteca 823-7104. ❑ Tracy 835-6385 Applicant - Retyrn all copies to: Envirohrental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE � INFO AMOUNT DUE i. AMOUNT REMITTED O # RECEIVED BY DATE PERMIT NO. e = i EH 14.28 + EH 13-24IREV.i/e Sl _ 13 s 0 i i