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APPLICATION FOR P! RMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � Telephone (209) 466-6781 ' PERMIT EXPIRES 1-YEAR FROM/ DATE ISSUED f (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. t Job Address 'r� City " Lot Size PM .. Owner s fVamelGedq I!° Address LLPhone Contractor Address " License No, Phone TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing lil F1 Public F1 Other ') Specifications Cl Delia Depth of Grout Seal Type of Grout _ + I i Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by! —+ Repair Work Done ❑ Type of Pump H.P. I _ State Work Done Well Destruction ❑ Well DiameterI! Sealing Material /top 50'} Depth Filler Material (Below 501 II" TYPE OF SEPTIC WORK: NEW INSTALLATION 1.7- REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Other Commercial vailable within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK t Water table depth ❑ Type/Mfg Capacity____" No. Compartments PKG, TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: = Well Foundation J Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation II # Property Line e SEEPAGE PITS I I Depth Size 1 Number SUMPS ❑ Distance toynearest: Well -Foundation DISPOSAL PONDS ❑ k ii Property Line I hereby certify that I have prepared this application and that the work will,ba 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: "1 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 pust call for all required in actions. Complete drawing on reverse side. Signed X Title: Date:A �46 FOR DEPARTMENT USE ONLY Application Accepted by 21I Date Area r Pit or Grout Ins �) pection ate Final Inspection Dby Data�� Additional Comments: # I ❑.Stk 466-6781 ❑ Lodi 369-3621 y ❑ Manteca El Tracy 835-6385 ,Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S F r� FEE AMOUNT DUE AMOUNT REMITTED CK INFO ASH RECEIVED BY DATE ,f �j WN . + EH 13-24(REV.t x 5) .15 `�� ,JY3S�� /fI`� i t