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w� 3y�i 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 Co Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address ? D �"�-�� C' ze PM Owner's Name r'es -/- Alext e/1, dress / PQ.[�l� Phone Contractor's Name .L�cense No. / 7 3 Phone v v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1PUMP 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth Elastern S ace Seal Installed by Repair Work Done Type of Pump H.P. .c State Work Done /S4WDestruction C Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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: 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 r to the San Joaquin Local Health District. Home ner or license agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not empl any person in su h manner as to become subject t rkman's compensation laws of California." Contractor's hiring or sub-contracting signature ce ies the following: " certify that in t#peornce t work for which this permit is issued, I shall employ persons subject to workman's compensa- tio laws of Cal' ni The applicant m' call for all requi dplate drawin on verse side. /Ql� Signe Title: Date: h'�'� 7 FOR DEPARTMENT USE ONLY /Q � Application Accepted by y Date -3 '—� Area 5 Pit or Grout Inspection by Date Final Inspection by wL Date Y 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 CK CASH RECEIVED BY DATE PERMIT NO. . EH 13-241REV. 10/831 3S - �O `"��)� �� gkc, b9 EH 1426 l�