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7,3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON 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 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 7-d -6 City 04 ' Lot Size PM U s � /,� 1 3 ' ]� �� ,-, PhoneJ3-3— b Z Owner's Name to v ii r Addres Contractor 4D'"""'-" v AddresscP "(� fig ' License N,/6-�7-3 Phon�/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ['S SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION, AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial fl Open Bottom ❑ Manteca Dia. of Well Excavation + Dia. of Wel! Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public F] Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation r -.—__Approx..-Dep ti A.]"Eastern ' Surface Seal Installed by - Repair Work Done 2- Type of'Pump H.P. State Workbone Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ) Filler Material (,Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I) REPAIR/ADDITION I ] DESTRUCTION l I (No septic system permitted if public sewer is R, available within 200 feet./ 3V Installation will serve: Residence Commercial— Other J Number of living units: Number of bedrooms + Il Character of sail to a depth-of 3 feet: Water table depth SEPTIC TANK ❑ Type""/Mfg' Capacity No. Compartments -- l PKG. TREATMENT PLT. ❑ Method of Disposal �4 Distance t6 nearest: Well - 'Foundations - - Prdj%ty Line ti) I LEACHING LINE ❑ No.&Length of'liiies _ r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Deptk Size Number SUMPS- -- - - Ll- -Distance-to-nearest:- Well - Foundation Property-Line DISPOSAL PONDS ❑ r 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, ar' rumles and regulations of the San Jo1.aquin 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 issued, I shat! not eploy 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all required i spections. Complete drawing on reverse side. 7- /✓ � Signed X tle: hate: F. EPARTiNENT USE ONLY / � Area Date r� Application Accepted by l Pit or Grout Inspection by Date Final Inspection by - r 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE ' t INFO CASCKH PERMITNO. +.EH 13-24(REV.1/R51 EH 14-26 i