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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. Job Address 1 R,,AL, ,- Ram& City Lot Size PM f Owner's Name `I� - Address �.4 4.AdA.J2_— Phone �T f --� c Contractor r771.P.�e� -,�; —�' cc— Address 059--i=059--i= i�.qL3n% (_(cense No. � ?6Z f J Phone -1S7'1 V� TYPE OF WELL/PUMP: NEW WELL❑,, r WELL REPLACEMENT ❑ DESTRUCTION ._ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation �,-Approx. Depth l I Eastern urface Sedl Installed by Repair Work Done Type of Pump /- -cam H.P. ;1-1 State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 50') C Depth Filler Material (Below 50 Of. TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION l I DESTRUCTION ( 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 bedi-o'dm's Character of soil to a depth of 33 feel - .. `^ "' '^ r �— Water-table-depth--_-- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG, TREATMENT PLT, 0 .—Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length•/`size`^'- Ar A FILTER BED ❑ Distance to nearest: WellFoundation Propecfy Line t SEEPAGE PITS I 1 Depth Size Number SUMPS L-3 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS:- . ❑ I hereby certify that I.have prepared this application and that the work will be dorie: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 must call f r all required inspections. Complete drawing on reverse side. Signed X� Title: Date: -90 OR DEPARTMENT USE ONLY Q� Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by pate !a [D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 ❑ Tracy 635-6365 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 ASH CK RECEIVED BY DATE PERMIT NO. a.EH 13-24(REV.1/H 5) j Cll EH 14-28 �a!/ —t 11