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L_ 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.( CCg f�1fC'yL� Job Address A 1 C LE R> ,,, ,_,�_ City Lot Size- �Li`� PM Owner's Name ) Address (1 �>1�� i A)19QPhone MAS,-r�w � ? t gra Contractor f `� � �� ddress <� �) •,,,,, --- License No. 5� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ,� '` a SYSTEM REPAIR ❑ OTHER ❑ -.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES kX)ti DISPOSAL FLD. AROP. LINE r FOUNDATION cC�' AGRICULTURE WELL /OTHER WELL_ 2Y-PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private $-Gravel Pack ❑ Tracy Type of Casing S Specifications ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal � _ Type of Grout I I Irrigation —Approxi Deth I 1 Eastern Surface Seal Installed by Repair Work Done { Type of Pump shrl H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material I8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION !-1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence Commercial_ Other Number of living units: . Number of bedrooms i 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 9 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 I I 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. rules and regulations of the San Joaquin Local Health Diltrict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The app"lc st call for all required ins ns. Co pl to dr Ing on reverse side. Signed X Title: � 06 2 Dater FOR DEPARTMENT USE ONLY Application Accepted by- Data Date 10 R Z ~, Area Pit or Grout Inspection by Date ifi !_ Final Inspection by 4 Date ZZ-2A 9'9- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 r ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE INFO AMOUNT D AMOUNT REMITTED CASH 'RECEIVED BY DATE PERMIT-NO. +.EH 13-241REV.Vies) 105 EH 14-26 - ! - PP-Z��?