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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL SHE_ALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA NO 1til ACL C - a .Telephone f 2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C {� (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 Ryles and Regulations of the San Joaquin Local Health District. ", f., ✓ Job Address f� " 1 City f r Lot Size PM Owner's Name 1 1 r f � ress 2, 1 v J , 7 i - Phone 7 b-> L w G Address r�osl1 / _ /C. Contractor �� License Ne Phone f� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ '•.PUMP INSTALLATION ❑ SYSTEM REPAIR;❑ OTHER C1DISTANCE TO NEARESTrSEPTIC TANK T SEWER LINES DISPOSAL FLD. PROP. LiNE FOUNDATION AGRICULTURE WELL "OTHER WELL PITS/SUMPS INTENDED IjSE�= ...TYPE OF WELL -PROBLEM AREA CONSTRUCTION-SPECIFICATIONS•""" II ❑ Industrial ❑ Open Bottom „1 ❑ Manteca —Dia. of Well ExcavationI Dia. of Well Casing 1111 ❑ Domestic/Private ❑ Gravel Pack j ❑ TracyType of Casing Specifications c f ❑ Public, ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grout / g ---Approx. Depth 1:1 Eastern Surface Seal installed by , Repair Work Done ❑ Type of Pump) H:P., State Work Done Well Destruction El Well Diameter "Sealing Material {top 501 ! J E Depth ' Filler Material (Below 50') TYPE OF;SEPTfC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION {No septic system permitted if public sewer is J� — available within 200 feet.) Installation will serve: Residence(L� Commercial— Other t Number of living units: Number of bedrooms l Character of soil to a dep;h of 3 feet: Water table depth SEPTIC TANK Type/Mfg a �- Capacity No. Compartments . PKG. TREATMENT PL ❑ # ' i ! � Method of Disposal 1 k` Distance to nearest: Well Foundation. Property Line i ! LEACHING LINE ❑ No. & Length of fines-------- Total Total length/size j FILTER BED ❑ Distance to neatest: Well Foundation Property Line } SEEPAGE PITS ❑ Depth -, Size Number ` SUMPS ❑ Distance to nearest: L .Well Foundation Property Line i DISPOSAL PONDS ❑ , ' s I hereby certify that I have prepared this ap rules andplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i 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:"I certify that in theperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- hlaws of California." The The app=46britt11or all-r sperm, o Com a drawing on reverse side. Signed Title: " w Date: A � t� RgD�E7 PAARTME111T USE ONLY Application Accepted by -4 qk; � Date Area Pit or Grout Inspection by Date Final Inspection by Dat 1 Additional Comments: ❑ Stk 4f�6 6781 ❑ Lodi 369-3621 f C1 Manteca 823-7104 ❑ Tracy 835-6385 h - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,:Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY DATE �7 PERMITpNO. + EH 13-24 EH 14-26(REV.F/a 5J (9C)