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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES`l'YEA-R'FROM DATE ISSUED (CrSmplete in Triplicate) Application is hereby made to the San Ji6eitluin 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 District. ,■ 2 Job AddressAleCity G /blot Size >�/ PM Owner's Name Address Phone UW7�E2 pzl') Contractor L/C/ +4 I`4 Addressw R2 14 License No.--110- 1 Phone � .TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ c�q�gy ,a?/}glY DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD-~ PROP. LINE FOUNDATION AGRICULTURE WELL BOTHER 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 kGravel Pack ❑ Tracy Type of Casing _ Specifications ,rte —C (-I'Public Ll O�)tter F1 Delta Depth of Grout Seal /�// rt•j,%aAflType of Grout Irrigation c2V Approx. Depth�f4 i I Eastern Surface Seal Installed by- �a� ] Are Repair Work Done ❑ Type of Pump �BRIn-hE H.P._,5=0 State Work Done_ " Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION t I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 l I Depth Size Number SUMPS Cl Distance to nearest: 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 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 applicant 5 I requi ons. Complete drawing on rev s Signed ZTitle: Date: CIL? FOR DEPARTMENT USE ONLY Application Accepted by t� �o-�^ -G- Date Area Pit or Grout Inspection by Date_ Final inspection by Date Additional Comments: LAY �`+>✓t�cY5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. + EH 13.21(REV.1/H5) EH 14-26 ' }