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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) 4pplication 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 nada in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin -ocal Health District. //0 7 L /j. G' / 0 lob Address / � CInn�tJJ�m__..+r��---- G�city�j per"- Lot Size pM Jwner's Name f��"�' i Address —/Z 7� /1- 7 Address php�6 Z, 9J ,ontractor Address 1.3� 7l- License No ,/�2373 p��3 C�-�f�_�'� -YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ASTANCE 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 epi a'6omestic/Private ❑ GfBvel Pack ❑ Tracy Type of Casing Specifications 7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 7 Irrigation --Approx. DeRth ❑ EasternSurface Seal Installed by tepair Work Done ElType of Pump H.P. 3 State Work Done'y"A_ Vell Destruction ❑ Well Diameter ® Sealing Material (top 501 Depth Filler Material (Below 501 ` 'YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted R 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 iEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments 'KG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .EACHING LINE ❑ No. & Length of lines Total length/size �ILTER BED ❑ Distance to nearest: Well Foundation Property Line iEEPAGE PITS ❑ Depth Size Number LUMPS ❑ Distance to nearest: Well Foundation Property Line )ISPOSAL PONDS ❑ 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 ules and regulations of the San Joaquin Local Health District. lome owner or licensed agent's,lsignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not mploy any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature ertifies 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 comperl ,on laws of California." 'he applicant st call for all required ' spsctions. mplete�drrawing on reverse side. / iigned X tie: �Li Date: O 1 FOR DEPARTMENT USE ONLY �1 application Accepted by Date A Area 'it or Grout Inspection by Date Final Inspection by Dale additional Comments: 7 Stk 4866/81 Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 83546M O'bo-C r.,d,p ,,.ell applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 UFEE � INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. CCC/// 24(Rev.pie s) m Ava(c �6�113s - o 0