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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. n //�'�� - TL �, ', w , Job Address�7 . a t -- City&Awo� Lot Size�� PM Owner's Name�""� ` � Address a6ox_ _/c;77_e - - r r 6 _164 ContractoAddresst/� �7`__� (P o License No. acv 2�tPPhane TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L 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 L Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private fJ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other 1-.1 Delta Depth of Grout Seal Type of Grout --- I I Irrigation _Approx. Depth I 1 Eastern y Surface Seal Installed by—.-- Repair y —Repair Work Done ❑ Type of Pump H.P. State Work Done __ Q Well Destruction ❑ Well Diameter Sealing Material (top 50') -- Depth Filler Material (Below-50') -- 1 TYPE OF SEPTIC WORK. NEW INSTALLATION' REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence= CommeeFial^ Other l • - Number-Of living units: Number of droo s 1 �v Character of soil to a depth of 3 feet: �- 102 - Water table depth__ v _ SEPTIC TANK _Type/Mfg,; _ Capacity No. Compartments — -- PKG. TREATMENT PLT. D + Method of Disposal Distance to dearest: Well Foundation __ Property Line -- f / r LEACHING LINE,-- No. & Length of lines — ,�'�lTotal length/size _ FILTER BED' D Distance to nearest: Well __ Foundation_ �� Property Line SEEPAGE-PITSDepth _ Size Number l SUMPS Ll Distance to nearest: Well Foundation —_- Property Line 12-- DISPOSAL- PONDS- ❑ Y 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 rules and regulations of the San Joaquin Local Health D3trict. `+ 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, t 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 follovJhg: "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 m all for al r uir inspections. Complete drawing on reversesi e( Signed X__ -- 4 �— Title: `�J•- - Dat7-e 1 FOR DEPARTMENT USE ONLY jr� -- Date ✓ � ��/ - Area _-� Application Accepted by --- --- der Grout Inspection by ato��final Inspection by Date i 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO ^) . EH 1324(REV.t i N 5) INFO qz,�� EH 14-2e LLL