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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 i Local Health District. City Lot Size Id 4 PM Job AddressQ } 1 ��/ A FCJ ,�� Address �av� '_ Phone 36 4 — f IV Owner's Name �^�,, Q Q -7 qg p, �!'� L'J7 License No. S Phone ��^ �� ContractorElddress TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYS EM REPAIR y OTHER ElLINE DISTANCE TO NEAREST: SEPTIC TANK ��f SEWER LINES �60 �-� DISPOSAL FLD. PROP. LINE /d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,�1 ❑ Industrial11 pen Bottom ❑ Manteca Dia. of Well Excavation t� Dia. of Well Casin v ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications (-I Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout_—_ rngation Approx. Depth t I Eastern Surface Seal Installedby rte" Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction [_3 Well Diameter Sealing Material Itop 501 — Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION t 1 DESTRUCTION i I (No septic system m permitted if wer is available withinInstallation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms i n Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK ❑ Type/Mfg Ca y No. Compartments PKG. TREATMENT PLT. Ll of Disposal I Distance to nearest: Well Foundation Property Line fY LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E] Distance to nea Well Foundation Property'Line. l t f SEEPAGE PITS l 1ee Number SUMPS Distance to nearest: �,�Well I Foundation'—t Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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 r 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 k f' tion laws of Califor t The.applicant m for s ns. Complete drawing on reverse side. Date: I Signed X FgWDEPARTMENT USE ONLY plication Accepted by "`z"t Date �/ / JOArrea ; !. r t N i f J S C aC a?4`� 1 r� ' Pit or Grout Inspection by — Date Final nsp tion by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3A21 ❑ Manteca 3-7104--<- ❑ Tracy 835-6385 Cc_ Wo Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box tk., CAS 0 16h3 yl"+! FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OAT - PERMIT NO. INFO +,EH13-24IREV.��FS51 r �`� �'/ I �a 1 •'� ��5 I - EH 14.29 G i