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UU f ~,APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICTS Z Z-- 1601 E. HAZEILTONAVE.,,STOCKTON, CA Telephone.(209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Jvaguin Local Health District for a permit to construct and/or install the work herein described.This application is I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18M for well/pump and the Rules and Regulations of the San Joaquin Local Health District.: A Jab Address 61: 4�u 19ci- City -0 �- Lot Size PM Owner's Name 4j /7 Address Sj9� Y Phone �� Contractor�l�l4V F• IwAqp—Address A /457 License No. Phone b .39� TYPE OF WELL/PUMP: NEW WELL L-1 'WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTAI TION ❑ SYSTEM REPAIR 111OTHER ❑ DISTANCE TO 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 ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 501 �\ Depth `• Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑*,FIEPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is f available within 200 feet.) 4Installation will serve: Residence A' c, Commercial:, Other. Number of living units: -L— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EJType/Mfg ! `t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total.length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' - I SEEPAGE PITS ❑ Depth ' Size Number SUMPS L-1 Distance to near&st: Well "- Foundation' Property Line DISPOSAL PONDS ❑ " 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 coy6pensation 1avrs of Califomia." 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- f tion laws of California." ' The applicant must call for all required ins ctions. Complete drawing on reverse side. Signed Title: _ Date: FOR DEPARTMENT USE ONLY Area ' Application Accepted by � Date '�' Pit or Grout Inspection by Date Final Inspection by Date (Ito z�Additional Comments: D Lt e�T r v 4 ❑ Stk 466-6781 . ❑ Lodi .369-3621 n Manteca 823-7104 ❑ Tracy 83548385 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 CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 1REV.1/8 51 EH 14-26