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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 TMs 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 , j Job Address 1L' : �i V 5�• L��tib( City HA GA Lot Sae P Owner s Name S f v/C r Address 4 A e Jri 41, (s Phone Contractor •41• f1t1 1��!d Address &' ✓ ArL 0r License NA6715 1— PnonA f TYPE OF WELL/PUMP NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ClOTHER ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom Manteca Die of Well Excavation Dia of Well Casing G Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 12 i f '7�^,J Z Specifications ❑ Public Other ❑ Delta Depth of Grout Seal Type of Grour 'f ! lil ❑ irrigation 10—Approx Depth ❑ Eastern Surface Seal Installed by r Repair Work Done C Type of Pump H P State Work Done Well Destruction G Well Diameter Seating Material (top 50) 0 tfr4-, 4C1)A)3 Depth 74 Filler Material IBelow 50) TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION a DESTRUCTION C (No septic system permitted if public sewer is • available within 200 feet 1 Installation mil serve Residence— Commercial— Other � Number of living units Number of bedrooms Character of sail to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal {� 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 t` SEEPAGE PITS ❑ Depth Size Number ` SUMPS ❑ Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 is 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 applica must call for al e�i tions Complete drawing on reverse side Signed T'rtte"'� i/�r�Clc}!O r'd r, y� Date � FOR EP SE ONLY Application Accepted b �� Date —19? a� Area dER Pit or Grout Inspection y Date Final Inspection by Date v All . SAdditional Gammen � -- J �'Stk 466-6781 ❑ Lodi 3691 ❑ Mantecai BZ3-7184 ❑ Tracy 835-6385 !/ Applicant- Return all capias to Environmental Health Pemut/Services 1601 E Hazelton Ave. P 0 Box 2009, Stk , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO 09 EM 13-24 j • EH 1/- (REV tiaSY 7 (/(,� {r ' �y. / :J �_.� _ (��Jf� •J