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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZEL T ON AVE., STOCKTON, CA l/ 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 � Y,(,7 . City 2t-rt, Lot Size PM Owner's Name dress , 3 3q Phone Contract t e2256 (�j��f 4 Address License N11,300-2-9 Phan 7 — Sg TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE • FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0Industrial Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F] Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Dia. of Well Casing g Specifications .` 1-1 Public CA Other ❑ Delta Depth of Grout Seal Type of Grout f I Irrigation --Approx. Depth I 1 Eastern 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') Z �- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms v �. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit p Y—.-�— No, Compartments PKC. 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 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 California." The applicant must cal for all r ctions. Complete drawing on r arse side. Signed Title: 3 I �� Date: FOR DEPARTMENT USE ONLY c2-.c� Application Accepted by Datz'� _ Area Additional Comments: Pit or Grout Inspection by Date Final Inspection by Date ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT'NO, `x +,EH 13-24{REV.v x sl EH 14-28