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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AYE., 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address -.99?0_ eh-4 o4c5,:5 Z4AJC City ZOA Lot Size PM _ Owner's Name AA✓0 Address - I�o��R//1/- [ ,1�7�q L+_�i ?"phone �S Z sN Contractor /N/AJG- OARS' �CAddress License No. Phone -UP- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ 0 pen Bottom ❑ Manteca Dia. of Well Excavation Jr, Dia. of Well Casing Domestic/Private '❑ Gravel Pack ❑ Tracy Type of Casing Sc,4 ?/,o e&C Specifications ❑ Public VOther ❑ Dena Depth of Grout Seal 1.4,� Type of Grout &M441q/TZr-_ r Irrigation �-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump _ _ H.P. _ State Work Done_ Well Destruction L_ Well Diameter Sealing Material (top 50'1 2&&arrA�Nlo,y,-c_ Depth Filler Material (Below 501 AQEA 6�;4AV&1— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other_ Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: Wdter table depth SEPTIC TANK ❑ Type/Mfg Capacity-----..- No,_Comp9rtments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &'Length of lines Total length/size I FILTER BED 0 Distarlce'to nearest: $Well Foundation Property Line SEEPAGE PITS ❑ Depth 'fie Number SUMPS ❑ Distance to nearest: Well Foundation Property Ling DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinX unty ordinances, state laws, and rules and regulations of the San Joaquin Local Health DisVict: 14i Home owner or licensed agent's signature certifies the folowing: "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 performance of the work for which this permit is issued,Fihall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: ?a'n'y winf�I F D P TME T USE 00 J Application Accepted - Date Area Pit or Grout Inspe ' b _ Final Inspection b Date Additional Com nt ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Magm 823- 104 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.Os1Box 2009, Stk., CA 9 (11 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT-NO. . EH 13-24(REV. EH 14-26 -�_