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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-Mll PERMIT EXPIRES 7 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. Job Address �� U U' r/��`5--- 2 City_J�- e-C, Lot Size PM Owner's Name 0 J"- �Y�G�I'I�_ - Address d� ylr is��v A Phone 3 11<� Contractor's Name•� af'f t�(I r s4�Y�� License No. 7 3 y'? IPhone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI ULTURE WELLOTHER WELL PITS/SUMPS y , INTENDED USE TYPE OF WELL PROBLEM A,- CONS UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications ❑ Public ❑ Other ❑ Delta. D th of Grout Seal Type of Grout ❑ Irrigation �Approx. Depth 0 East"rn Su Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �+ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units. Q Number of bedrooms a Character of soil to a depth of 3 feet: $Jry 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 iengthlsize FILTER BED Distance to nearest: Well Foundation f� Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 i 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 airing 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 applicant must Call for all required inspections. Complete drawing on reverse side. Signed ` ` � Title: r d s as o y Date: 12� FID MENTUSE ONLY Application Accept y Date Area Pit or Grout Inspecti y ate Final Inspection by Date/Z��7 Additional Comments: ❑ Stk 466-8781 ❑ Lodi 319-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6'385 Applicant- Return all copies to: Environmental Health Permit/Services 1e01 E, Hazelton Ave., P.O. Box 2009; Stk., CA SMI FEEDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO ` r EH 13.241 REV.10163! cu i��c 1