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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'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 j made in compliance with San Joaquin County Ordinance No. 548 for sewage or No- 1862 for well!pump and the Rules and Regulations of the San Joaquin l Local Health District"] a Job Address 1 City Lot Size PM Owner's Name �� ` i 1CA1�J+�Address '6LO9 I� I�• 1a�1_� `� Phone(' r I N ,,11 Contractor�Al-Tl^7M\kN Address ill 0 S License No C-931EK-Phone_M[2911 Mc TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �1 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 /1,/ DISTANCE TO NEAREST: SEPTIC TANK1JaSEWER LINES e DISPOSAL FLD.NQ PROP. LINE _ FOUNDATION is 1J F AGRICULTURE WELL 9-0--0E—OTHER WELLPInSJt=, PITSISUMPS l�Q C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ii)\JC_ Specifications M PublicD her )< Delta Depth of Grout Seal '�CtL Type of Grout I I Irgigadon Approx. Depth l I Eastern Surface Seal Installed by�r-M\R RepCaii-rt'VorT Done ❑ Type of Pump H,P, State Work Done � Well Destruction ❑ Well Diameter Sealing Material (top 50'1 6� Depth Filler Material 1 Below 50') �3r, TYPE OF SEPTIC WORK: NEW INSTALLATION € I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial' Other r '` Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED d Distance to nearest: Well Foundation Property Line SEEPAGE PITS I t Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "t 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 laws of California." Contractors 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 persons subject to workman's compensa- tion laws of ifornia." The appli nt ust call tar I req 'red - s ctions. Complete drawing on reverse side. Signed Title- Date: �/ 1 t7-� l� �,�3-Y�tJ `-G tit S C �I D { `^t_ 5�± O DEP RTMENT USE ONLY i Application Accepted by W W0. Date Area_t r Pit or Grout Inspection by Date Final Inspection by Date l—Z g"—q Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health PefmitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT }�REMITTED CASHH/� RECEIVED BY DATE PERNO, NO. . EH 13-241REV.i/x51 - .dQ I 14-29 Mx- EH Ji