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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON 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. Job Address �® /'z` City df. Lot Size PM f 02 7 Y36 Owner's Name !ham Address J� Phone } C �� License No. -1W Phone Contractor Address 6p � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll REPAIR LJ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom - ❑.Manteca Dia. of Well Excavation Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public f 1 Other Cl Delta Depth of Grout Seal Type of Grout — i i I krigation=y Approx. Depth i I Eastern Surface Seal Installed by - 3 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction t ❑ Well Diameter Sealing Material {top 50'I ;i Depth Filler Material iBelow 50'1 REPAIR/ADDITION DESTRUCTION ( INo septic system permitted it public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION . r^ / '�,,• available within 200 feet.] � 1 -`installation will serve: Residence�C Commercial_. Other Number of living units: � t Number of bedrooms GLI— ' Character of soil to a depth of 3 feet: _"nd�r I©�A'�- � Water table depth SEPTIC TANK LW'Type/Mfg i.o c h —4 IIA — Capacity.1G Q No. Compartments PKG_, TREATMENT-OLT. 0 Method of Disposal Distance to nearest: Well Foundation Property.Line i LEACHING LINE o. & Length of lines U 1166 Total length/size FILTER BED ❑ Distancelto nearest:, Well Foundation,/© f- Property Line /® ir. sr SEEPAGE PITS M'Depths Size� Number ' SUMPS ❑ Distance to nearest: Well /fib J Foundation Property Line -DISPOSAL PONDS ❑ 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X UAZ Title: Date: FOR DEPARTMENT USE ONLY A plication Accepted by Date Area P' or Grout inspection byate LA Final l spection b Date I �, �' 'Fir 1 ____ '. - 7 Additional Comments: A�4)16 1 113 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health"Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT'DUE AMOUNT REMITTED ASH RECEIVED BY GATE PERMIT NO. INFO 1 f r.EH 13-24 IREV. /N 5) EH t4-28