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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 G PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is hereby made to the San Jo aquin 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. f - 1t Job Address 751TO e-,eA City L Lot Size PM Owner's Name ,FRAA$-,'_ VA Address I Phone Contractor Address s• QuxGe_nse NoPhone TYPE OF WELL/PUMP: NEW WELL Df, WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES _PISP_OSAL-FLD. U�-� PROP. LINE FOUNDATION AGRICULTURE�WELL? OTHER WELL PITS/SUMPS '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 'T & racy Type df Casing&C- &,:z Pd/ Specifications �` [ Public F1 Other i ❑ Delta Depth of Grout Seal �� Type of Grout&AOAW I I Irrigation M /60-Approxi Depth I i Eastern Surface Seal Installed by E' Repair Work Done ❑ Type of Pump H.P. _ - - State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 501 IF ,--{ Depth Filler Material [Below 501 TYPE OF,.SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION C)" DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other — Number of living units: Number of bedrooms 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 r } _ Distance to nearest: Well _ Foundation Property line l -� ♦mss ,, ,r�. j LEACHING LINE ❑ No. & Length of lines -- -- "-Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Number SEEPAGE:PITS I I Depth - Size SUMPS i' Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . ❑ k 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 Ortify that in the performance of the work for which this permit is issued, I shalt employ"persons subject to workman's compensa- tion laws of California." The applic u all or all re u-ed i tions. Complale drawing on re ase side, 'p Signed X Title' Date: FO SE dN Y k r Application Accepted by Date bF Area00 _ T Pit or Grout Inspection by Date OW Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 +`z Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. IN �1 f. r.EH 13-24(REV.t/x 51 a b-C) EH 14-28 k