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APPLICATION FOR PERMIT i 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 and the Rules and Regulations of the San Joaquin Local Health District. (. Job Address City Lot Size PM Owner's Name t ��{� �'�� Address ��"l�, Phone /.lJJg7��L ContractorAQWA9?11�75 Addresscr�_License No. �'�� Phone TYPE OF WELL/PUMP: NEW WELL,9p WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION _ SYSTEM REPAIR ❑ OTHER ❑ D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE a 2" FOUNDATION AGRICULTURE WELL OTHER WELL—IS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )VDomestic/Private >VGravet Pack ❑ Tracy Type of Casing Specification ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type�f Grout ❑ Irrigation OiMpprox. Depth 0 Eastern Surf. a Seal Installed by S Repair Work Dane ❑ Type of Pump vL ___ H.P. f �— State Work Done Well Destruction ❑ Well Diameter —Sealing Material (top 50') ( , . Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION E REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Q available within 200 feet.) Installation will 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 CapacityNo. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal s 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be d6n-e in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. •N 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 applicant2�?� quired in mplete drawing on rave side. Signed itle: — iA� - Date: FOR DEPARTMENT USE ONLY/ Application Accepted by Date LA Area COO Pit or Grout Inspection by Date Fina`I Inspection bz, 14"� Date Additional Comments: Cj4_44-rw t&Q a \t-+«.� G'�-�+:.��A ❑ Stk 466-6781 Ll Lodi 369-362 0 Manteca 823-71IN ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASCK H RECEIVED BY DATE PERMIT'NO. k EH 13-24 iREV,1/e5) _��g� p os EH 13-28 / ``��