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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEi.:TON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 appllcation is made in compliau!ce with`;an Jnsouin County Ordinance No.549 for sewage or No.1862 for wellfpump and the Rules and Regulations of the San Joaquin rL Local Health District. Job Address / �� r)�lL�.•i!-iL.- �. (7 7 / City i-' ; Lot Size ' 'l�z'�`}' PM Owner's Name ,//- ``'C Address. /,_, C L r ,_�7L� ti-�L1 y�/ Phone tContractZi J . t YCI __ i r License No.' �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE iFFf FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑Open eottom ❑Manteca Dia.of Well Excavation Ria-of Well Casing ' ❑Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications ❑Public ❑Other ❑Delia Depth of Grout Seal Type of Grout 0 Irrigation ---Approx.Depth ❑Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done F Well Destruction ❑ Well Diameter Sealing Material(top 501 r ILA f Depth Filler Material IBelow•50'1 - v6t i j TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR ADDITIO - DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial Qther f Number of living units: Number Character of soil to a depth of 3 feet: -1,_ Water table depth �J E SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE fd�No.&Length of lines_ ,< �C Total length!size 'G' 1k "-- FILTER BED ❑ Distance to nearest: Well $Z Foundation i C Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 - -wles 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 Tssued,I shall not 4 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- sill for all re uire inspections.Complete drawing on reverse side Signed � � �f- '�-�- Titls: E� �. Date: 6vu--c i FOR DEPARTMENT USE QNLY y� Application Accepted by Data Area I� Pit or Grout Inspection by Data Final Inspection by Datea5� Additional Comments: 61 ❑Stk 466-6781 ❑Lodi 369-3621 ❑Manteca 923-7104 ❑Tracy 8356385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 FEE INFU AMOUNT DUE AMOUNT REMITTED CK It CASH RECEIVED BY IDATE P8nMIT No- EHn-2SInEv.irasi 70 c3Q Sipb �1P1137 EH„-za f. s. ,