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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. Job Address �4f �i<!` {A 7�s�, City /t'f1�+l�fV Lot Size^ � LPM Owner's Name,P 'I- �y 'i� Address h+ �`I ` /� c �j Phone Contract3o.,f,t �y �� '� ��"' tldress / � License Nom% 'ynT Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR C1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK fJ�v SEWER LINES -1-- DISPOSAL FLD. PROP. LINE FOUNDATION �f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CJ ❑� In/�dustrial pen Bottom ❑ Manteca Dia. pf Well Excavation Dia- of Well Casing LwDomestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications / I'1 Public cal1711tOther F1 Delta Depth of Grout Seal C7 Type of Grout_ -- IUIrrigalion 75`�Approx. Dep�t,h��I I Eastern /Surface Seal Installed by - Repair Work Done ❑ Type of Pump '!_1441_ H.P. [ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (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 r Character of soil to a depth of 3 Water table depth SEPTIC TANK ❑ Ty /Mfg Capacity,- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well- Found_ atti Property Line LEACHING LINE ❑ No. &Len h-6f lines Total length/size�- FILTER BED ❑ Djsi ce to nearest: Well Foundation Property Line SEEPAGE PITS I II Depth Size Number SUMPS [_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 person in such manner as to become subject to workman's compensation 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." The applicant must call for all requlrod i pections. Complete drawing on r e vers side. Signed X_,G' 11�" Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by yg Date3 —+Z — Area_ Final Inspection by ,� r-,'/"J,' -- Date Pit or Grout Inspection by 1Q Y �L.l�Y nw.:�t< nom'" 15C2 ,;S,-7&- Additional Comments: �Q1�.-1. � � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �� -3.— FEE AMOUNT DUE EAMOUNTMITTED SRECEIVED BY DATE PERM N ..INFO dEH 13.241REV.1�M5) \ Q� i 5-71 �� EH 14-29