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(� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZELTON 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. ll Job Address City NLot Sizee:fA6f PM Owner's Name [ Je15 Address: l/�( � Phone r Contract) orl5 t(:;��Vl P4 1 dress' _._License NoPhone � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ "DISTANCE TO NEAREST:,SEPTIC",TANK_ SEWER LINES- � DISPOSAL FLD; PROP. LINE SL' FOUNDATION AGRICULTURE WELL WOTHER 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/ Gravel Pack, ❑ Tracy Type of Casing Ct�� Specifications I� Fl Public ❑ Other I Delta Depth of Grout Seal Type of Grout /Vf I I Irrigation _.Approx, Delith l I Eastern Syd�Face Seal Installed by Repair Work Done PQ Type of Pump iVJP5m H.P. State Work Done Well Destruction D. Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 f TYPE OF SEPTIC ORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet:) .yam Installation will serve: Residence_ _Commercial Other l Number of living units: !Number of bedrooms -� Character of soil to a depth of 3 feet: ""* " -' *" Water table depth SEPTIC TANK ❑ Type/Mfg "2 Capacity ' No. Compartments PKG, TREATMENT PLT. D_ w Method of Disposal Distance to nearest: Well Foundation " Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - C {v. SEEPAGE PITS I 1 Depth Size Number ' l SUMPS ❑ Distance to nearest: Well Foundation Property Line N DISPOSAL PONDS ❑ 1 C> ' 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 DFstrict. 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 call for all required inspections,ocsimplete drawinp on rev se side. 4 F� Signed X e: _ '1 /�/ y / / 1 �3' Date: FOR DEPARTMENT USE ONLY Application Accepted by _. _ Date o —4.S Area Pit or rout spection by Date Final Inspection by ' '�5` Date 7 Additional Comments: J �� ❑ Stk 466-67881 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOiJNT REMITTED " K H RECEIVED BY DATE PERi4t1T'NO. w +.EH 13-24{n EH 14-28 EY.ii>ttO Orj"_