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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) J 2 C)q- 1.90-o? 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 k 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. l w*t ? lPMQ/ Job Address, ritY Lot Size „` Owner's Name I—•RIf3• Address PhoneR35 ; 91 A 4 c Contractor �) Address,►0r 77� icensewNo.J � —flnone_ , TYPE OF WELLIPUMP:. NEW WELL WELL REPLACEMENT © DESTRUCTION IJ UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Pi-, �U / DISTANCE TO NEAREST: SEPTIC TANK �rtQ� SEWER LINES 5Q) --- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (� y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial ❑ Qpen Bottom ❑ Manteca Dia. of Wel! Excavation ^" Dia. of Well Casing 9 DomesticIPrivate Y13ravel Pack ❑ Tracy Type of Casing Pyle, Specifications' �J l'1 Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout — .1 IW-Approx. Depth I 1 Eastern Surface Seal Installed by 41 5 I I Irrigation i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 1 ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION lit REPAIRIADDITION LI DESTRUCTION I i Mailable within system rented if public sewer is - I Installation will 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 f Capacity No. Compartments PKG. TREATMENT PLT. EI _ Method of Disposal II� Distance to nearest: Well Foundation ProjieRy.Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS L1 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 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 applican ust call fora)) required inspec'ons. Complete drawing on reverse side. "� .F.clr�1.�+1�¢r2WA /�"5 . C' �+ Date:! Signed X Title: T DE6_RTMENT USE ONLY ; Application Accepted by Date` Pit or Grout Inspection by Date �r Final Inspection by Date Additional Comments: moo! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentecpr 82f7A ❑ Tracy 83 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 958 r I FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. INFO _ +,EH 13-24 1REV.1/n 51 � EH 14.28