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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 1 Z 5 33 fU l� Q s City (�Lot Size . Z A C_ PM Owner's Name ��eR QA �N AddressPhone qs(— 03j Contractor :� Address✓, u a 17 License IYo.3 7� 14'S Phone y' t r TYPE OF WELL/PUMP: NEW WELL 19 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAILLATION,046 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLO. PROP. LINE 90 FOUNDATION—_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom 5 Manteca Dia. of Well Excavation Dia. of Well Casing G �6 Domestic/Private >@ Gravel Pack ❑ Tracy Type of Casing PyC Specifications l`1 Public F1 Other F1 Delta Depth of Grout Seal too 3 Type of Grout Ct Ir! h^t _ } I i Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by A- o Repair Work Done ❑ Type of Pump' H. _� State Work pone O Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 .: Depth Filler Material IBelow 50') W TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other \v� Number of living units:. Number'of bedrooms Character of soil 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 lines Total length/size { FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation' Property Line DISPOSAL PONDS ❑ t 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, aA rules and regulations of the San Joaquin Local Health Di$trict. 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 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: "l 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 must call for all required inspections. Complete drawing on reverse`side. Signed X Title: Date: L'�"` g R FOR DEP RTMENT USE ONLY Application Accepted by� _ Date �`- j�� Area Pit or ro Inspection Date l! Final Inspection by Date JZ Additional Comments: ❑ Stk 466.6781 ❑ Lodi . 369-3621 ❑ Manteca -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 — 4N RECEIVED 9Y INFO C $N DATE PERMIT'NO. a.EH 13.24 IREV.t/H 51 EH 14-26