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APPLICATION FOR PERMIT SON JOAQUIN LOCAL HEALTH DISTRICT-' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 C 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. 3a5P�Nor* O �ee � lJob Address City Lot Size PM Owner's Name l wW Address 52S W•Jlil r JI St 4c-X� CAPhone 20—.99Z-0 'S V ITE $ FaxmatrT)GA Contractor lIe?CZeoS %+eMS Address 437 Ss MISSIhN 51—VO A License No.CZG 12(- 4- Phone IS-foS - TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L _ Dia. of Well Casing -19ernee' '�Gravel Pack ❑ Tracy Type of Casing 4' 'P 'acyl 40 Specifications ❑ Public O Other ❑ Delta Depth of Grout Seal "�� r Type of Grout nom' t ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 1� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 11 Sealing Material (top 501 Depth ^' So' Filler Material(Below 501 TYP SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted'rf public sewer is available within 200 feet.) Installation wi rve: Residence_ Commercial_ Other Number of living un Number of bedrooms Character of soil to a dept f 3 feet: Water table depth SEPTIC TANK ❑ Typ fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nea t: ell Foundation Property Line LEACHING LINE ❑ No. & Len of lines Total length size FILTER BED L1Dist a to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Found .� Property Line DISPOSAL P DS ❑ 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 shall 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 rformance 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 r all re it ins Complet drawing on se side. Q Signed X it V IV -/ � Date: / FOR DEPARTMENT US LY Application Accepted by / ,Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: O 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 FEE AMOUNT DUE AMOUNT REMITTED S RECEIVED BY DATE PERMIT NO. INFO ` `rye'-�-- 1 O EH 13-24(REV.1 n 5) xr , • �� CS . Cl /b/ EH 14-26