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i APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r y, (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, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ! e e City Got Size M Owner's Name 0. Address I ow Phone Contractor . ^'hv�. ;Address + License No. 7 Phone 4h(oG+ bZ I TYPE-OF_WELL/PtJMP: , sNEW.,]Nl LL 0 .� - - 'WELL'REPLACEMENT-❑_:_ -DESTR_UCTIO_N LI PUMP INSTALLATION SYSTEM REPAIR 1-1 f O+HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. # PROP. LINE FOUNDATION 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 ❑ Grave! Pack ❑ Tracy Type of Casing Specifications (� 1-rr'I Public f_} Other ❑�Delta Depth of Grout Seal Type of Grout I`i' - rgationApprox. Depth lKEastern Surfaac� Seal Installed by - a Repair Work Done /Type of Pump 7) ,- - H,P. State Work Done es Well Destruction ❑ Well Diameter" Sealing Material Itop 501 Depth Filler Material {Below 50') { TYPE OF SEPTIC WORK: `'NEW INSTALLATION Ia REPAIR/ADDITION LI DESTRUCTION l I (Nq,septic system permitted if public'sewer is available within 200 feet.) Installation will serve: Residence—1 Commercial`.' Other -- '^�~• /�lltt"_J� ' 1 Number of living units:-a Number of bedrooms t • ?- Character of soil to a depth_of 3 feet: "'i - Water.table depth I SEPTIC TANK ❑ Type/Mfg W Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal ' i Distance to nearest: Well and - n Property Line LEACHING LINE ❑ No. & Length of lin s _ - Total length/size T FILTER BED ❑ Distance to neares p Well t �' Foundation Property Line } ti .r a SEEPAGE PITS i I Depth ' ize Numbe I SUMPS I--] Distance to Weare We ` ll "" Foundation'' S ' I Pr6pe Line 1 DISPOSAL PONDS ❑ i 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, an i rulesand regulation San Joaquin Local Health Di$trict. Home owner or -rise'age is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any p s in such anner os becom u iect to workman's compensation laws of California." Contractor's hiring of sub-contracting signature i certifies the olio ng: "I ify i at i the rf rice of the work for which this permit is issued,1 shall employ persons subject to workman's comp-rise ` t tion laws f Calif r The app cant st c for ctions. -e yawing on reyde. ' a Signed Title: r V Date: R DEPARTMENT USE ONLY II ' Application Accepted by Date Q, Area + Pit or Orout Inspection by Date Final Inspection by T')V,-\ qDateA Additional,Comments: t ❑ Stk 466-6781 CJ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ---� Applicant - Return all topies.to:-Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED— CK-0 RECEIVED'BY f DATE_-, - PERMIT No. INFO CASH -_ - ♦.EH 13-241REV.1/H5) EH 14-26 i