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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. l Job Address /'s-es/ ),>z S C�Z`,Q d /�, - - -- City ' r a� G Lot Size - C/-e—PM Owner's Name /h h 6`� /r� Address Z*-�—, + Phone 6S23 " ContractorOf dG']`{�%!�" �d Address T'0.,fox 92 -.. Xq'I b-CQ,License No.Lf` C346 23 Phone l' TYPE OF':WELL/PUMP: - NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ x_ PUMP INSTALLATION` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK bo` SEWER LINES /oo` t DISPOSAL FL000 PROP. LINE �d FOUNDATION 66 AGRICULTURE WELL OTHER WELL � PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / 4 ❑ Industrial ❑ Open Bottom 4 Manteca Dia. of Well Excavation !2` Dia. of Well Casing �{ V Domestic/Private X Gravel Pack ❑ Tracy Type of Casing V V Specifications C`R_5s /e6 ❑ Public_ ❑ Other ❑ Delta Depth of Grout Seal ASO - Type of Grout` ^2 / e J ❑ Irrigation 4R-k-Approx, Depth ❑-Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump e H.P. State Work Done Well Destruction ,p-,a Well-Diarneter, Sealing Material,(top 50'1 4 Depth Filler Material (Below 501 TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public seweti 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT_PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance wA San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-HeaIth•Disfricf" — - - , 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,],shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re ired 'nspections. Complete drawing on reverse side. y� Signed X C.JG!/✓+�-- � Title: � ''7 �`�`� �� Date: `� T—GS� EPAR-EMENT USE ONLY Application Accepted � L Pit or Grout Inspection by r Date Final Inspection by Rate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835400 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 CASH CK RECEIVED BY DATE PERMIT NO. + EH 13-24 4REV.1,a s) EH 14-28 +