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A'4 APPLICATION FOR PERMIT , F SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR 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 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 In rcity 6iot Size PM ED Owner's Name Address 05MPhone �4"- ;n 4wy �J/� Phone - g Contractor U�Address Ia-� License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public I_ Ogler n Delta Depth of Grout Seal Typipof Grout _. I d ation � 0-Approx. Depth t 1 Eastern Surface Seal Installed by t a oniS' ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i'I REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 leet.) Installation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feetr Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. (71 Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total iengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line f. SEEPAGE PITS l I Depth Size Number SUMPS Ll 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. 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 shalt 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,1 shall employ parsons subject to workman's compensa- tion laws of Calif ia." The applica m call f re ui d in cti omp a drawing Conn reverse side.( I� }�A�^ Signed X Title: Z--J�_R.•__-E�k6'. 1'+n 1 Date: as i FOR DEPARTMENT USE ONLY Application Accepted by 10 _ Date Area Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: f a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hezelto vs., P.O. Box 2009, Stk., CA 95201 " ' /��/ r✓C:Y/f ir7SQc G 24;-e,�7 f w FEE AMOUNT DUE AMOUNT REMITTED CK 49 H RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24 4REV.i i n 5) ws EH 14-26 /