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y 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 No-549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addressr�25tS"4 �,�n"(/�/CC�ity�l _�'��, Lot Size PM Q7 Owner's Name /t-��S''�I>.t/ / �Al 49722 Address ��// ,��J'Phone Contractor eV-4 . /Y//�V6 .Sy'S Address � ss 1a6 A2Z/—c,::2 license No.'YFPhone m3� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION;WDFALA46W41'$TEM 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 L5 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy ,Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump <5�—JCK H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Z !rf Z"Ir1 - Depth Filler Material (Below 501 TYPE OF SEPTIC WOV: NEW INSTALLATION-41 REPAIR/ADDITION 1.1 DESTRUCTION I 1.INo 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: _ Water table depth V SEPTIC TANK O Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑• Distance to nearest:'. Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size - Number SUMPS L1. Distance to nearest: • Well Foundation Property Line DISPOSAL PONDS Cl - 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, and0 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 perform of the work for which this permit is issued, tion laws of California." I shall employ persons subject to workman's compensa- The applicant 11 quired " s',. plate drawing on re rse de. r� Signed X Title: Q� Date: _ r57 le/ COQ FO DEPARTMENT USE ONLY Application Accepted by � Date Are 0,5 Cmc Pit or Grout Inspection by Date Final Inspection b Date' li_00 Additional Comments: > ❑ 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, Sik., CA 95201 FEE AMOUNT DUEE[n.REMITTED CK RECEIVED BV DATE PERMIT'NO. NFOCASH EH 124(REV.vx sl O s EH 14-a9 /1`1/ g 8 8 aie3