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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I_ 1601 E. HAZEi,T ON�, VE., STOCKTON, CA Telephone (2091'466-6781 PERMIT EXPIRES TYEAR 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 i 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 City Size PM 4+�rsn Phone �3-03 [ Owner's Name"'Con9 L �7 5'iv/ ztractor Address -�7 Z e '` �%License No. PZ5 d�J Phone / /'��y S _ TYPE OF WELL/PUMP: m" NEW WELL F] 1NE'Ll'REPL-ACEMENT•T❑ - --- -DESTRUCTION-3 - PUMP INSTALLATION ❑ SYSTEM REPAIR iW OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- -_X' ' l51SPOSAL FLD. 9'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom EI Manteca Dia. of Well Excavation •� Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy= Type of Casing Specifications r F]l Public Ll Other Cl Delta Depth of Grout Seal Type of Grout _. I I Irrigation �Approx. De t�h.+ I Tstam__ _ _ _ Surface eal Installed by Repair Work Done [Er/ Type of Pump W H.P. State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material [top 501 = Depth Filler Material-I Below 501 - -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/,ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet_1 Installation will serve: Residence_ Commercial o Other,T.�— ; 00 Number of living units: Number of bedroomsi, _ ,. Character�af soil to a depth of 3 fear. 71ines r "r` t Water table&pth ' SEPTIC TANK. ❑ Type/Mfg '' Capacity No. Compartments' PKG)TREATMENT PLT. ❑ Method of Disposal Distance to neareWell Foun on Property Line LEACHING LINE `•❑ No. & Length of Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line v SEEPAGE PITS { I Depth1ze Num SUMPS - Ll Distance to nearest: Well Foundation �P_r- y Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this applicationlarRI that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Healtl`6611 'ict. Home owner lar ' 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 rson in suc nner as to beco a subject to wor Cman's compensation laws of California." Contractor's hiring or sub contracting signature certifies t following: "I'ce "fy that in the ormanc he work for which this-permit is issued,I shall employ persons subject to workman's compensa- tion law of Califor ia." E The app icant II req e i omplet drawing on sid Signed X Title: r Date: OR DEPARTMENT USE ONLY q Application Accepted by Datea 3` 1-1 Area _ I Fait or Grout Inspection by Date Final Inspection by� Date 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 i 11 FEEL qAM�OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +-EH 13-24iRM1/851 � al ff tV '23.. e k- EH 1426