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APPLICATION FOR PERMIT u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTOWAVE., STOCKTON, CA "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. 18&2 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address J Ci C PM Owner' LLLG 4atX.0 Phone w —J �� r IC47 Contractor Address aicense No �� one TYPE OF WELL/PUMP,?4 ,; NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ - - _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Pubes ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ice,rr�igation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work.Done �Type of PumpD w T H.P. 7C State Work Done bow Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIG]/YORK: ?NEW INSTALL4TION ❑ ;REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200`feet.) + Installation will serve: Residence_ Commercial—Other Number of living units: Number of4 bedroorns�ti{ Character of sail to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg c. T Capacity r ,'No. Compartments PKG. TREATMENT PLT. El �_ _� -�� ._ 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 ❑ Depth _ Size ~ - Number SUMPS ❑ Distance to nearest: Well r Foundation Property Line DISPOSAL PONDS ❑ t 1 hereby rtify that I e prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules a regulations of t San Joaquin Local Health District. ' Home wrier or licensed ag nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not empl y any person in such nnejin become subjec orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certi les the following: "I c thhe rman of t work for which is permit is issued,I shall employ persons subject to workman's compensa- tion laws of California The pplicant must fo all reqi c' plete d ng erre side i ' Signed Title: 4444 Rafe: ZO DEPARTMENT USE ONLY ` Application Accepted byAir Dai . �Q ea Pit or Grout inspection by bate Final Inspec on by Date 6-kY Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO / CASH ` + EH 13-24{REV.t/B51 EH 14-26 I