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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 Ql+f D� /'d/C t✓ WC/�/✓o. Z 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. 0c _(� /� Job Address � w t� �� ,/,Je. City^pPa0l Lot Size PM O/wner's Name^_/�0/�O�/Qy�{—� (�D Address�� N�k 7�7 �io p,, Z%4 9s.?6 6 Ph k�g— Z�/ Contractor Address Ud/Aa1"Cc°f115� License No.JT.?2*:�-7 Phon& #— A� yr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 640�$01%" 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: ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I INo 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. Cr �hlpartments 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 I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that II 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 appkanntu''stcall lffor all required inspections. Complete drawing on reverse side. Signed xfeTitle: Date: ?f�q FOR DEPARTMENT USE ONLY Application Accepted by Date $ Area 074 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-36211.,, ❑,Marrieca 823-7104'~ ❑ Tracy 835-6385 !+ Applicant - Return a10 copies to: Environmental Healtfr Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 "r EEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 111-29 3-21(REV EH Sv sL) r'�S �� ` J J 1 y� �pq(0