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APPLICATION FOR PERMIT 3fc� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED ° (Complete in'Triplicate) 1 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 Jdaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District. , �f +r Job Address/ �` City �V '� Lot Size -. PM Owner's Name I dres� �+a�t Phone-c Q j 0 r � 13-23 i Contractor Address//®NI ' License NoPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ S, PUMP INSTALLATION B' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAf3EST: SEI?TIC 7ANC'n SEWER.LINES_ DISPOSAL` FLD: _ PROP. LINE ; FOUNDATION ^ AGRICULTURE WELL OTHER WELL + rPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i41domestic/Private ❑ Gravel Pack: ❑ Tracy Type of Casing ' Specifications ❑ Public C7 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___4pprox. Dep ❑ Eastern Syrface Seal Installed by Repair Work Dong UKType of Pump H.P. 1 State Work Dorer Well Destruction ❑ Well Diameter Sealing Material (top 50') _,J► I Depth c3�---� `1- Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer,S available within 200 feet.). DQ Installation will serve: Residence 1. Commercial_ .Other `+` :'• } Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:-- rr.�j Water table"depth. : f SEPTIC TANK ❑ Type/Mfg A. Capacity No. Compartments ; PKG. TREATMENT PLT. D f Method of Disposal Distance to'nearest: Well �' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distanceo nearest: Well Foundation Property Line i r SEEPAGE PITS ❑ Depth A Size Number i SUMPS ❑ Distance to nearest: Well Foundation Prope4 Line DISPOSAL PONDS ❑ � I II 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 ol rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I sha14 not a. 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 applican st gall for al re 'red inspections. Complete drawing on reverse side. Signed X j tle: Date: p b FOR DEPARTM. NT USE ONLY IV Application Accepted by 4 Date �G Area �� L Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ';,.❑ Tracy' 835-6385 i Applicant- Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520.1 FEE' AMOUNT DUE' AMOUNT REMITTED CR RECEIVED BY DATE PERMIT`NO. INFO } CASH + EH 13-241REV.i/a5) .:3Z5, 00 1 EH 14-28 f �