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APPLICATION FOR PERMIT d l' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Q / � A/ Sd �� /\[� City of Sizet� PM ~ Job Address Id6 a( —„ /OGO 4QPhone��`�` `6' Owner's Name t I/ Address , to �a�/ _ Contractor r t@ Address .�� [9c�aIcense No. �T��"?,� Phone �� /�' 7 TYPE OF WELL/PUMP: NEW WELL W--- WELL REPLACEMENT 9;— ^ DESTRUCTION ❑ ,ter PUMP INSTALLATION LF , SYSTEM REPAIR 71❑p1SPOSAL FLD OTHER fl OP. LINEvr� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � T^" ` FOUNDATION�� AGRICULTURE WELL �ppi7THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� Q ❑ Industrial Open Bottom Y ❑ Manteca Dia. of Well Excavation Dia. of Well Casiri9 I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing V Specifications Neal Il Public ( I Othr�rf [71 Delta Depth of Grout Seal 0 Type of Grout /OA rox. Depth { 1 Eastern Surface Seal Installed by��j"/�/e� . I I irrigation pp � Repair Work Done ❑ Type of Pump H. —�N' State Work Done _ ' Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is #. available within 200 feet.) lnstallatioA will serve: 'Residence— Commercial Other I Number of living units: Number of bedrooms depth table de Water p Character of soil to a depth of 3 feet: -�. SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments ` I PKG. TREATMENT PLT. LI Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINEA _ —0 -No. & Length of lines._ Total length/size °. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE-PITS -1(,,l Depth Size Number SUMPS 0 `-Distance to nearest: Well Foundation 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 District. I Home owner or licensed agent's Sig natur'e.,certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 cornpensa tion laws of California." The applicant St call for all required inspe tions. Complete drawing on reverse side. Signed X l L I �-+ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by C.n Date Area � 7 Pit or Grout Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO WSJ Jif,%G . EH 1324(REV., x 5) iYT .�3 - A► �" / r�� • K+ 'EH 14-26 �� pp 2