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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 a6iiihe Rules and Regulations�of the San Joaquin Local Health District. Job Address �7 � Alt-1OC4� �n7 yt p City � Lot Size PM Owner's Name �/�.��/PIPP�" Co Address /90 &V �S 97�i? Ch 9,.?6/6 Phone(�s�7" 4e V1 9,6 Contractor Address2��//��i^,�Pf019 License No.S�p44 7 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Ir*#. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK )V-4 SEWER LINES 1 Sao/ DISPOSAL FLD.N '!9. PROP. LINE �3a l FOUNDATION �- AGRICULTURE WELL N•f3 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q�Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z© Dia. of Well Casing 0,0 [_1 Domestic/Private ok Gravel Pack ❑ Tracy Type of Casing Ntile P/ Specifications f`] Public 1-1 Other ❑ Delta Depth of Grout Seal ��✓ Type of G t r0� �l'/1JF. _ 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 I ) DESTRUCTION l 1 (No septic system permitted if public sewer is w, available within 200 feet.) 1_ 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 v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q 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 ta. SEEPAGE PITS I I Depth Size _ Number SUMPS t_l 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 G 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 applican /dust call forr fall required inspections. Complete drawing on reverse side. �+ Signed X4�G�1� C�� CoQ CJ Title: / t Date: z/_/ DEPARTMENT USE ONLY Application Accepted by Date �� Area Pit o Grout Inspection b Dgate ction by Date Additional Comments: / v ; �/ 1 ❑ Stk 466-6781 ❑ Lodi 369-3651 O 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 a FEE AMOUNT DUE AMOUNT REMITTED INFO /CASH RECEIVED BY DATE PERMIT NO. a EH 13-24(REV.t/rt 5) �v� �� EH 14-24 LLL f) r