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APPLICATION FOR PERMI-IT SAN JOAQUIN LOCAL HEALTH DISTRICTrl ;�' 1601 E. HAZELTON AVE., STOCKTON, CA � I Telephone 1209) 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. (� yp� `� /J - r Job Address J /✓ /A/-,UC_/ ^�i--1�20 -I " Citys�_ Lot SizeI t� PM Owner's Name Address Phone. 16 /O6& � Contract 4 AddressA YQ776,7 je/,C/ License N1&2y9 fa Phone 9-6-/U \ NJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ O it 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 SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t L ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Material (Below,50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION Tr DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2011 feet.) Installation will serve: Residence_ Commercial_ Other ` Number of living units: / / —(_ Number of Broom Character of soil to a depth of 3 feet: _ ,i`r�J"'� 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 P'-No. & Length of lines Total length/size 111 X FILTER BED ❑ Distance to nearest: Well - Foundation Propertyline •�/ r SEEPAGE PITS ❑ Depth Size ��"n' � U Number SUMPS Z/Distance to nearest: Well-4C 6 Foundation_�(�_il 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 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 parson in such manner as to become subject to workman'scompensatidn 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." ape - - �' The applicant must II for all requ' d in ctions. Complete drawing on reverse s de. U`y Signed r_L// Title: A! 2 Date: O C FOR DEPARTMENT USE ONLY Application Accepted by r Data Area o low Pit or Grout Inspection by Data 6 Final Inspection by Date ` Additional Comments: _ ❑ Stk 466781 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BV DATE PERMIT'NO. `.EH 13-zd 1aEV.Ii55) EH 1d-28