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—low APPLICATION FOR PFERMIT t s2 =5a SAN JOAQUIN LOCAL HEAL H 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 find the,RUtgs and Regulations of,the San Joaquin Local Health District., r' Job Address �!- SCS. V C L,.`.� City AM p ✓r m qtr k i.: Owner's Name f Address l�'� ' 'Oht o{�q, Contrac ors Name License No. phQ� _Zy2CY TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ pEST#ttJC7lON'p 1 4a t PUMP,INSTALLATION ❑ SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4:. r. DlSPOSA;L FLD% <r+ PFIQMINE, " }� _- --FOUNDATION- AGRICULTURE,WELL rte' OTHER WELL i �" PITS/Si�jMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 15 Manteca Dia. of Well Excavation ' v iia of V4�ell G`asirig' ]f Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifica}gns ❑ Public ❑ Other 0 D Delta Depth of Grout Seal Tape pf`Grctut{ ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed_ by Repair Work Done ;K Type of Pump 3 - H - ) State W_Qrk Done !�w Well Destruction ❑ Well Diameter Sealing Material (top 50') } Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ (No septic-system pe rmitted^if+public sewer is ". available With"In200 feet f 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. 11M.ethod of Disposai « - Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. ✓?t Length of lines Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Property Line r ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance tcnearest: Well 'Foundation Property,Line DISPOSAL PONDS D t I hereby certify that I have prepared this application and that the work will be done in accordance with S8r Jpaquin county,gr finances, stats 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 inithe performance of the work fpr which this permit Is issued, I shall not employ any person in such manner as to become subject to workman's-compensetion laws of California."Contractor's hinng or sXcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject f©workman's compensa- tion laws of California." - - s I d The applica call for all require specpo" '.Comp to drawing on reverse side. Signed T - TV i y Dat= k l �� FOR DEPARTMENT USE ONLY Application Accepted by TN _-Date Pit or Grout Inspection by Data Final Inspllct on�by•• Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 • ❑ Manteca 823-7104 ❑ Trecy 835-63!15 i Applicant- Return all copies to: Eri+iironmental Health Permit/Services 1601 E. Hazelton Ave., P O fox 2DBtkFEE CA 9501 i y INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 53-24(REV.101831 EH%28 ,� s E s cBS :o- 4 .,