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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE►TON AVE., STOCKTON, CA pAYMEHT Telephone (209) 466-6781 R E G E IV F-0 PERMIT EXPIRES 1 YEAR'FROM,-DATE ISSUED' (Complete in'Triplicate) h ,. ,. J UL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein tWNME atM44LCH made in compliance with San Joaquin Couniy Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulan Local Health District. Job Address -�LL�►^�i�( i City Lot Size a ` f PM �:.�,�s Owner's Namelit�� lt�/ Address "° -� 17�1_C.s Phone To Contractor Address IL27 Wa.-4—,1;4if&42,fk_ License No.%!57Z.2 M .Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ rSYSTEM REPAIR ❑ OTHER k q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IA Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern u, Surface Seal Installed by n Repair Work Done IQQ Type of Pump r,a H.P.` !/2 State Work Done /��} \ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ 1No septic system permitted if public sewer is ' f . available within 200 feet.) Installation will serve: Residence-_' . Commercial_ Other Numbe Number of living units: rtof bedrooms Character of soil to a depth of 3 feet: Water table depth • SEPTIC TANK ❑ Typee/MfgCapacity .No,..Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line L: 1. LEACHING LINE ❑ No. &,Length of lines Total length/size FILTER BED ❑ Distance to,nearest: Well Foundation Property Line P SEEPAGE PITS ❑ Depth}% Size Number r4 SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ r 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. - r 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." fa I I r The applicant must call for all required inspections. Complete drawing on r erre side. � l Signed X Title: �.l�z Date: /Zrj1 l.. FOR DEPARTMENT USE ONLY Application Accepted by � Date /�l—a' Area Pit or Grout Inspection by Date Final Inspection by - Daterr�' `a i Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 t ❑ 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 FEE INFO AMOUNT DUE f AMOUNTREMITTEDCASH RECEIVED BY DATE PERMIT'NO. ` + EH 13-244REV.1/e51 � V Q ��Vu 106-2.. Z;2/7W � ff 11EH 14-25p