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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 City District. ` \ Job Address 1 (. ^1�� �•C.�QuK C_L -NLot Size PMIf Owner's Name Addressfl "' ` Phone ... _ _ Contractor C��llC,� W`L� Address �L L• 1. License No.� 1�L p Ph4i, 46 3, _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 using ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specification ❑ Public ❑ Other L] Delta Depth of Grout Seal Type of Grout L] Irrigation ----Approx. Depth ❑ Eastern urf ce Seal Installed by �. LL Repair Work Done ❑ T p P Type of Pum H.P. P State Worjc Done Well Destruction ❑ Well Diameter Sealing Material (top 50') � Depth Filler Material (Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑.-DESTRUCTION Ll (No 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 __ WaterFtgtf�_dcp(h SEPTIC TANK L] Type/Mfg Capacity---- No. Compartments PKG. TREATMENT PLT. LI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE -1 No. & Length of lines _ Total length/size FILTER BED L) Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I 1 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 reions of the San Joaquin Local Health District. Home owne or ensed 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 a;UX tojece subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies tn thrmanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws The applid io s. C plete drawing o everse si Signed X Title: _ , Date: q W"V/3 i - FOR DE ARTMENT USE ONLY Application Accepted by __ Date I� Area " PifWf—Grobt"Inspection by Date Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. � . EH 1 -241REV,i Ks1 EH 1 4-26 �._ �____ /� � �b-�Cl