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p } APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED (Complete in lriplicat6ll ro 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 Rifles and Regulations of the San Joaquin Local Health District. Job Address T2 -��► �" ' � "f i City dv Lot Size PM Owner's Name - Address z `� i Phone Contractor-0!9 '"i ^64446d" 6 446d y _ Address1/W01V V icense No IKSY2b1 Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REia 1R ElOTHER l ,r, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "V1 x FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 01 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing iir Domestic/Private El,Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑:Otherl�:■ F '�.,` . ❑"Deli'a� r Depth of Grout Seal ,_. _Type of Grout . ❑ Irrigation f ---Approx. Depth Eastern Surface Seal Installed by Repair Work Done Z' Type of Pump H.P. t Work po e Well Destruction ❑ Welll Diameter- Sealing Material (top 50'1, IV o . Depths' Filler Material (Below 50'1 -t'""� f j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION x (No septic system Oetmiftbd,if public sewer is 1 available within,206,f$ef:) Installation will serve: Residence; Commercial_ Other 'fes Number of living units: Number of bedrooms Character of soil:to a deptVof 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 lines Total length/size FILTER BED ❑ ;Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ ,Distance to nearest: Well Foundation Property Line 1 - DISPOSAL PONDS ❑� _ - - .. I hereby certify that I have prepared thislapplication 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 signature certifies the following: "I 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, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant st call foyiMyequired inspections. Complete drawing on re .rse side. y Date:Signed X Title• F R DEPARTMENT USE ONLY Application Accepted b Data Area Pit or Grout Inspection by Date Final Inspection by „ ( Date I 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 1 FEE AMOUNT DUE ' AMOUNT REMITTED K RECEIVED BY DATE PERMIT`NO. t INFO C + EH 13-24iREV.t/e5} EH 14-26