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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. Des `IZ_� l a Job Address � _ ,�C%� � City Lit Size PM _ Owner's Name � 0—l-6 W' AddressS.� www Phone W_/00 Contractor �� Address it7Aab License No. Phone �00C� fi TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 2, utis✓l S --RM-. . - _ - �-w-PUMP INSTALLATION..❑ ,.�- r:;, SYSTEM-REP_AiR._❑ � OTHER DISTANCE TO NEAREST: SEPTIC TANK ; SEWER LINES DISPOSAL FLD. PROP..LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION}SPECIFICATIONS O..Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack N ❑ Tracy Type of Casing 1 Specifications _ F1 Public H Other FI Delta Depth of Grout Seal Type of Grout _ � �I IlIrrigation. _.Approx; Depth l I Eastern Surface Seal tnstalled by .Repair-Work Done •❑Type of PumR H.P. State Work Done . . .Well Destruction ❑ Well Diameter Sealing Material (top 501 "_Depth Filler Material (Below 50'I , TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION LI DESTRUCTION-( 1..INo,septic system permifted if public sewer i -'.•available Within 200 feet.) Installation will serve: Residence_' Commercial— Other Number of living units: Number of bedrooms t `� Character of soil to a depth of 3 feet} --�' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ �. - 4 Method of Disposal Distance to nearest: W 1 Foundation Property Line � { LEACHING LINE ❑ No. & L i of lines Total length/size- FILTER BED ❑ ance to nearest: Well Foundation Property Line I _ SEEPAGE P [ I Depth Size 'Number SU LlDistance to nearest: Well Foundation Property Line SPO SALPONDS ❑ 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: 1 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 applica t all to at squired inspections. Complete drawing on re arse ide. / t T a �� T7 Signed X R Title: Z Date: FOR DEPARTMENT USE ONLY Application Accepted by __. _ Date Area Pit or Grout Inspection by Date Final Inspection by Date I l Additional Comments: w"v►t + !1 h � . Cl Stk 466-6781 ❑ Lodi 369-3621 Mantec ll/ 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13-241REV.t�H51 EH'14-25 f