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APPLICATION FOR PERMIT , , SAN JOAQUIN LOCAL'HEALTH DISTRICT �l 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" (Complete in Triplicate) s. 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 Rules and Regulations of the San Joaquin Local Health District. Job Address � City ` Lot Size PM - Owner's Name • ✓ G "/Address �p" ylZ� =PhoneI _e= - Contractor ! Address Pd '�v X /12-7—License No.�6�3( Phone 7 jr 6 Z TYPE OF WELL/PUMP:" NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR le' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind trial ❑ Open Bottom F1 )Manteca Dia. of Well Excavation Dia. of Well Casing aU mestic/Private I] Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ stern Surface Seal Installed by Repair Work DoneQ/ Type"of Pump H.P. Z-� State Work Done L Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .DESTRUCTION ❑ INo septic system permitted if public sewer is H` available within 200 feet.) C _ , Installation will serve: Residence— Commercial_ Other Number of living units: _� Number of bedrooms a "� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No.--&-Length of lines Total length/size 1 FILTER BED ❑ Distance;#o-,nearest. Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ' .❑. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ "'SII 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 Sam�Joaquin Local Health District. Home owner or ' 'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 4 employ ariy pe on in such.mann as"to become sutijeci f—workman's compensati6h laws:-of-California."Contractors hiring or sub-contracting signature certifies the fol wing: "I ce 'fy t t in a performance. he.work foh"this,permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca ornia." The applicant m st r of r r !red in cti wing reverse si Signed "Date: FOR DEPARTMENT USE ONLY ?' Application Accepted by I� }Date o—kk + + Area " Pit or Grout Inspection by !� Date Final Inspection by t Date Additional Comments: s C�ttk 466&781 ❑ Lodi 1369-3621 ❑ 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 INFO CASH RECEIVED BY DATE PERMIT NO. + EH1324 fREV.I/a E) EH 11428q.7 's C ,