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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. E / Job Address 79�D 'V �`y City Lot Size X PM �cu�1��PV p�fei�G Owner's Name �� rs ✓ro"Address Phone /e W X14 0 U� 4fls Contractor �c� 4-®�p Add-r ss 45_5_�0'�� icense No. Phone 1, TYPE OF WELL/PUMP: NEW WELL E) WELL REPLACEMENT ❑ DESTRUGTtON PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, tae— ee&,fU6j_5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLN�5D PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Other '[A (_, F7 Delta Depth of Grout Seal �.� Type of Grout o WO tF` I 1 Eastern Surface Seal Installed by I I Irrigation �Appr - Repair Work Done ❑ y e Pump —_ H.P. State Work Done Well Destruction 11ameter �� Sealing Material (top 50') Depth i Filler Material IBelow 50') 9 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feetA 0 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 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 SEEPAGE PITS l I Depth Size Number SUMPS hl 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: "! 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: "!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 Cal' mia." The applican scall r all re wr in Complete drawing on reverse side. Signed X Title: Date: FO�EPART NT USE ONLY Application Accepted by �h _XZZ'I Date Area_ t Pit or Grout Inspection by Date�T Final Inspection by Date t Additional Comments: c- fOVk ❑ Stk 466-6781 ❑Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-5365 Applicant- Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. r-yyy� INFO CASH r EH13-21(REV.tirr5) EH 14-26