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APPL[CATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT :bp ,}` ' ` is�d��. F 1601 E. HAZE.T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F' �� .tela a (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. F1 . gel A t ��,{--� � A��s PM Job Address � City Lot 5iz .� 1 Owner's Name �� Z/9�U Address rZ<6�/ /�' �DY _ Phone) '`J/ l 4 Contractor's Name G License No. Phone �� + TYPE OF WELUPUMP: WELL REPLACEMENT EJDESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK sJ r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑__�Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing QC fJ Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l F ❑ Public ❑ Other Ci Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth 1� Eastern lurface Seal Installed by Repair Work Done ❑ Type of Pump -�� - - H.P. 13 State Work Done s rA`1-- to + Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 'S . ,-. Installation will serve: Residence_ Commercial_ Other Nu, of living units: Number of bedrooms A 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 rrl Distance to nearest: Well Foundation Property Line A Fk - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line { SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ + 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 FFF_ rules and regulations of the San Joaquin Local Health District. j 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, l 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;I shall employ persons subject to workman's compensa- tion laws of California." _ The afpplicant must`all for all required i spect' ns. Comple drawing on reverse side. Sign I Title�� '�� J k_zc `� Date: j a ' FOR DEP RTMENT USE ONLY Application Accepted by "'ter D LZ Date Z/ Area Pit or Grout Inspection by Date Final Inspection by Date �! •.rte Additional Comments. O Stic 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. -i EH 13-241REV.t01831