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i 3 APPLICATION.FOR PERMIT SAN JOAQUIN'LOCAL`HEALTH DISTRICT 1601 E. HAZELTON 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 N .549 for sewa e . Na.1852 for well/pump and the Rules and'Regulations of the-San Joaquin Local Health District. Job Address / �-�'�`�� 8L mss'Ste • City- _-5T/fr1_\1, Lot Size PM � Owner's Name T21 /s✓ Address Phone �f/w Trp- f ContractorI�DR�YIh'fi/5 3Snddress �7 >�.zCC�k iU3License No.��' S3�1� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 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 SPECIFICATION$' ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,bomestic/Private ❑ Gravel Pack ❑Tracy Typo of Casing Specifications C7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ lrrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump SjOB H.P. State Work Done L Well Destruction ❑ Well Diameter Sealing Material(top 501 Ji1tle,,2 Depth Filler Material{Below 50') 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_ CDmrn r4al_� . Other' Number of living units: Number of bedrooms " Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neatest: - Well Foundation Property.Line LA 0 a LEACHING LINE ❑ No. &Length of lines Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well— Foundation Property Line 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 f 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 performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion lavas of California." The applicant f all re inspections. Complete drawing �Meside. Signed x� r [/ � � Title: �!�� Date: FOR DEPARTMENT USE ONLY Application Accepted b f` Date 2-/0�, 7 Area f Pit or Grout Inspectio y Date Final Inspection by Date— Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FETE AMOUNT DUE AMOUNT REMITTED C INFO CASH RECEIVED BY DATE PERMIT TIO. +EN 13-24(REV.I/a 5) 51- ` %E5 EH 14-26