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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 City /v Lot Size PM G� syr �C3 Owner's Name _/"!�/� 3,/�/yJJ /�� rAddress ::2 S^Z 4- > /l _ /f✓`TPhone Contractor Address License No.!!5 r /�Phone TYPE OF WELL/PUMP:R , NEW WELL Cl.. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JV 46ZAAeOAKSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + Ll Domestic/Private -❑ Gravel Pack ❑ Tracy - Type of Casing Specifications f'l Public Cl Other f.-1,Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx: 'Depth I ] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _.._,_ � H.P._ __ State Work Done Well Destruction ❑ Well Diameter # Sealing Material (top 501 � {»� Depth 1 x Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATION I ] REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic stem permitted if p y p 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. & Lengthlof lines - --. .:. ''- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f Property Linex SEEPAGE PITS i l Depth F Size i Number SUMPS CI Distance to nearest: r Well Foundation Property Line,\ DISPOSAL PONDS ❑ 1' 411 tO, .N^k - I hereby certify that.I have prepared this application and that the work wild be done_in a_ccordance;'with San Joaquin:couniy'ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.---- """ �� •{ 't_ Home owner or licensed agents signature certifies the following: "!certify_that-n-the-performance of the work for whi this permit is issued, E shall not employ any person in such manner as io become subject to workman's compensation laws of California.''-Cbncractor's hiring or sub-contracting signature *. s ,P - certifies the following: "I certify that in the performance of the work for which this permit is-issued,i shall employ-personasubject to workman's compensa- tion laws of California." 1t' t+i: •, R 4 t`f - -The applicant all.re pections. Complete-drawing•on-re4 rs� ide: -77 ^+ Signed X Title: Data: . FOR'DEPARTMENT'USE'ONLYt Application Accepted by - -- -- Dates= Area — ID Pit or Grout Inspection t Date Final Inspection by Date i' Additional Comments: e. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environm ntal Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH KO RECEIVED 6Y DATE PEE(R�MI7'NO. a.EH13-24IREV.1/H5) EH 14-26