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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6784 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby (Complete in Triplicate) 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.543 for Local Health District. 'age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Y Job Address f. „� City Lot Size PM Owner's Name / } Address �c�l�I��Phone Contractor—Az-4, 1 [1-6- _.Address �/!�^Ic+ TYPE OF WELL/PUMP: License No o� Phone NEW WELL ❑ WCL EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D �.: T*SY,STEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK i OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL{ d OTHER WELL INTENDED USE . TYPE OF WELL � PROBLEM AREA CONSTRUCTION SPECIFICATIONS ¢ i ❑ Industrial .. ❑ Open Bottom ❑ Manteca- - Dia. of well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T, ❑ PublicType-of-Casing-,... Specifications Cl❑ Other t LJ Delta Depth of Grout Seal EJ Irrigation —Approx. Depth ❑ Eastern Type of Grout Repair Work Done ❑ Type of Pump j Surface Seal Instelled.by H P i Well Destruction L] Well Diameter > State Work bone Sealing Material (top 50') ' Depth I Filler Material (Below 501) j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES7RUC7fUN (No septic system permitted if public sewer is Installation will serve: Residence Commercial— Other� } available within 200 feet.) r� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. Ll _Capacity No. Compartments E r v Distance to nearest: Well Method of Disposal y Foundation »Property Line LEACHING LINE ❑ No. & Length of lines # FILTER BED Total length/size ❑ Distance to nearest: Well Foundation t : # Property Line SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ Distance to nearest: Well . Foundation � r"� DISPOSAL PONDS ❑ Property Line. u � K 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 District. s 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 certifies the following:"I certify that in the performance of the work for whichuserlaws of'California." ed,I hi ll Contractor's hiring c sub contracting signature tion laws of California." s permit is issued, I shall'employ persons subject to workman's compensa- `� I The applicant must call for'all r fired ' spections. Complete drawing on reverse side:� G Signed Title: ,„,.. Date: � t 'w FOR PA NT USE ONLY Application Accepted by i --D Date b l a IJ Area Pit or Grout Inspection by r Date Final Inspection by ' f• r Da}#e Additional Comments: � �„rv��-� t ❑ Stk 466-6781 ❑ Lodi 369-3621 It ❑ Manteca 823-7104 ❑ Tracyti 835-6385 Applicant- Return ail copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .». ..-,,,... .. ��.........,. .--.,_..�........._.. ,�.,.-. AMOUNT REMITTEDF4�!T ..d. RECEIVED BY _�-,.�..,...r...r....-,._.._..,�... ---.....-,,, '. FEE AM �U�� CKINFO DATE PERMIT`NO. EH 14-24 IIiEV.„a s, _� EH 14-28