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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 Distrito, Job Address / 3 "y-�rQIL1-�j�1t,., City Lot Size PM Owner's Name, �� Address (WXPhone t Contract Address &r 7Z'7 license No3zsZZ-6 Phone y-L00� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU ON ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �THER P L FLO. PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS IN_ INTENDED USE TYPE OF WELL PROBLEM AREA CONS TION SPECIFICATIONS -1 Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack LI Tracy Type of Casing Specifications Cl Public F1 Other - to Depth of Grout Seal Type of Grout ' i I Irrigation —Approx. De I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of P H.P. State Work Done - ` ,' Well Destruction ❑ iameter Sealing Material Itop 50'1 V Depth Filler Material {Below 50'1 t _ - TYPE OF SEP ORK: NEW INSTALLATION i 1 REPAIR/ADOITIONh I IDESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: ResidenceCommercial_ Other �( I Number of living units: - Number of be roams Character of soil to a depth of 3 feet: Water table depth �d t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ry LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property.Line SEEPAGE PITS I I Depth 3 0 Size • jr _ .Sl F Number SUMPS �01 Distance to nearest: Well 10115 ` Foundation . 147 z 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 compensation taws 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." t The applicant must II for all required inspections. Complete drawing on reverse side. } Signed X Title: a1912.2 Date: /d -2-4 -X 9 FOR DEPPA TMENT USE ONLY Applic 'on Accepted by Date�� 4L-_R7Area ' or Grout Ins tion by J o 'Z Date. /0 fFiFinal Inspection by at r Additional Comments: "— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ` AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. ♦.EH 13-4-2e 24 IREV.t/:a sl FPW::�rj J?q-P?(p071 ` EH 1 ��r' LLL