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.r APPLICATION FOR PERMIT r 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 he+eby 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 y —R�f►1 G ' , City Lot Size J0 �Lc ' PIM �! Owner's Name + 6 Address ((r it e-NIf AC- Phone — Contractor Address V: i�f��i`- CS�i� Lice nse,No;s3'7-[ - Phone9 - 7 a 7 aTYPE OF WELL/PUMP: NEW WELL NWLL REPLACEMENT ❑ —DESTRUCTION-E]--- PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ��.. DISTANCE TO NEAREST: SEPTIC TANK ht1P.C' SEWER LINES n A 1! DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LDhr' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t w D OomesticlPrivate C] Gravel Pack ❑ Tracy Type of Casing-49e Specifications t a 1�1 Public ❑ Other ❑ Delta Depth of Grout Seal ��[`� Type o Grout�it_eil2r frriyationApprox. Depth I I Eastern Surface Seal Installed by Repoli 1M17ork Done L7` Type of"Pump�—H-P:c �-- -State-Work-Do,o _ Well Destruction L7 •Well Diameter Sealing Material (top 50') T Depth Filler Material (Below 501 TYPE OF SEPTIC WORK 4NEW INSTAtLA47T-ION-1=1--'RERAIRLADDITEON I I' DESTRUCTION i I (No septic system permitted if public sewer is� ` available within 200 feet.) { r Installation will serve: Residence_ Commercial_ Other r Number of living units: Number of bedrooms ti 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. & Length of lines Total length/size �� J FILTER BED ❑ Distance to nearest: Well Foundation Proparty Line SEEPAGE PITS [ I Depth Size t` Number SUMPS Ll Distance to nearest: Well Foundation _ Property Line 'DISPOSAL a PONDS ❑ `--'I he-reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, atidA rules and 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 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: t .:sr'S Date: fi FOR DEPARTMENT USE ONLY r Application Accepted by CiLr`^ VV% f, rRAanA�CA Date Area v IlkPit or rout pection by }w \ L� L Date-t Final Inspection by ��""� Dat ' Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E RECEIVED BY PERMI AMOUNT DUAMOUNT REMITTED � DATE � FEE CK T N0. INFO CASH ♦.EH 13-24(REV.i i n 51 1.V `tQ`q1 EH 14-28 0 1 . L i