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APPLICATION FOR PERMIT +� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA 9 a ECEI VED Telephone 1209} 466-6781 D E C 6 19$9 PERMIT EXPIRES TYEAR FROM DATE ISSUED ':i {Complete in Triplicate} NVI t 0,'W ENTAL HEALTH PERM11 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein esc licauan 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. ' i Job Address 12 E fz�)Ci I dw.64 Zia N v City Svice]"_A-iAt Size PM Owner's Name Address Address , N Phone Contractor �.L +nom Address ?O Z� -._. License No. 73 Phone t146 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0L--'-_" OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL IOTHER WELL PITS/SUMPS i 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 FI Public I-I Other ❑ Delta Depth of Grout Seal Type of Grout _ P. - 1 I I Irrigation / _..Approx. DeDW. th�,�l I. astern, Suriaatce Seal Installed by i Repair Work Done LT Type of Pump 1.W.T H.P. ,[J State Work Done die Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below.501 TYPE Of.SEPTIC WORK: NEW INSTALLATION l;lREPAIWADDITION t:) DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) DO Installation will serve: Residence_ Commercial Other t Number of living units: Number of bedrolsihs i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal (� Distance to nearest: :Well: Foundation Property Line 50 LEACHING LINE ❑ No. & Length of.lihes_ Total length/size i Y 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number S i SUMPS ❑ Distance to nearest: Well Foundation Property Line i 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 perso nner as to become subject to wotkman's compensation laws of California."Contractors hiring or sub-contracting signature k certifies the fo ing: "I ce ify that in th orm c of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of alifomia." The appli nt mus c o all re i eta drawing on e e sl '00Signed Title: Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by Date ��" Area Pit or Grout Inspection by Date Final Inspection by Q�i Additional Comments: ❑ Stk" 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy .835-6395 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Silk., CA 95201 CK f INFO AMOVNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-26(REV.i 1 n 5) � EH 14-28