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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-tTON AVE., STOCKTON, CA Telephone 12091466-6781qffl PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �C\ , (Complete in Triplicate) . ,� r�PR��;JyS Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herdrq,d�n . Thrs application is �.v,. made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 186'1 for well/pump and the Rules ��ggulatiorts of the San Joaquin Local Health District. r� f Job Address �/r�i� �ry ��/ Lot Sizet. 9 � PM Owner's (Name / �L[�1�d4 SI-40p4dtlress y �/� m� Phone � I Contractor __ _ ddress No. Phone TYPE OF WELL/PUMP: _ NEW WELL V WELL REPL,4C ENT"C7 'DESTRUCTION-❑'=""- PUMP INSTALLATION ❑ r``SYSTEM REPAIR ❑ • OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL�PiTS/SUMPS INTENDED USE TYPE OF WELL 4PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� Industrial 00 0 n Bottom 1❑Manteca Dia. of Well Excavation Dia. of Well Casing lrSDomestic/Private R ravel Pack 2T cy Type of Casing .8 f>Q Specifications ❑ Public ) ❑ Other t ❑ Delta Depth of Grout Seal 1 Type,of Grau ❑ Irrigation !(AD >N—Approx. Depth ❑ Eastern Surface Seal Installed by �r; Repair Work Done ❑ T PumI_-Filler H-P -•---y- - State Work Done C p Type of PC Well Destruction ❑ Well DiameterSealing Material (top 50') Depth , - 6 Material (Below 501 TYPE OF'SEPTfC"WO'RK'-Mr= !"INSTALLA-rgN ❑ REPAIR/ADDITION q DESTRUCTION ❑ (No septic system permitted if public sewer is �� - �� •--.•- _' t:. `i available within 200 feet.) Installation will serve Rebid nce_ Commercial - Other "'-- -•-, "4;�q Number of Iivirig.urnts.t x Number of bedrooms ' '^ Character of soil to a depth of 3 feet: r Water �table depth SEPTIC , _ SEPTIC TANK ❑ Type/Mfg „.. Capacity It No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal :. i \ "_ % ' e� Distance to nearest: Well foundation Property Line u LEACHING LINE ❑- -No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: V611 Foundation Property Line k SEEPAGE PITS` Cl Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS O 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 California." I The applican st yfa�ll�' dctions. Complete drawing on reverse side. f Signed Title: Date: f r FOR DEPARTMENT USE ONLY-1 s �Application Accepted by Date r _ Area -Pit or Grout Inspection by Date dp rP 767 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 7104 ❑ Tracy 83546385 I� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED tCi4KSH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/s5S EH � s`4 .5 ' 1428 L �` �