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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 r (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 f Local Health District. .. l 5i_ l.:S. MrVILT �. c� Co1.� 4 go 1.6 ce Job Address . City Lot Size PM 8q7- Owner's Name Address Phone 7F' rn/QV�S , ` �Addfess License No,3ZJ21 Phone Contractor --TYPE—OF—WELL/—RUMP:: ,,ANEW WELL ..a -�� wELL_REPLACEMENT_E_ DESTRUCTION ❑ W--'PUMP INSTALLATION © SYSTEM REPAIR ❑ _ OTHER © DISTANCE TO NEAREST: SEPTIC TANK L200(L SEWER LINES 'DISPOSAL FLD.L�KkPROP. LINE FOUNDATION AGF ICULTURE WELL ,-OTHER WELL PITS/SUMPS � y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation & Dia. of Well Casing (\) Ef�nmesticlPrivate CSI' ravel Pack ❑ Tracy Type of Casing -Ie Specifications Q 1`I Public n Other ❑ Delta --- Depth of Grout Seal r Type of Grout I I Irrigation _.-Approx.,De tth�• i I Eastern Surf ce Seal Installed by Repair Work Done LL3�7ype of Pump s�3�� H.P. State Work Done T Well Destruction F_ Well Diameter Sealing Material (top 50') Y C-) l Depth "` Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR IADDITION 1 F DESTRUCTION I 1 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 ! r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. b ° r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines /Total length/size t 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 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 signatures 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." r The applicant call or all required inspections. Complete drawing on rev se side. s Signed X ` itIe: Date: - _ FOR DEPAR ENT USE ONLY ; Application Accepted by Date �, e Area Pit of Groy Inspection by Date Final Ins ction by .Date Addi ion!r/,fnr. nts: �C!/G` �Y �✓ -� r/! /F C�iG ��`" E3 Stk 466-6781 n-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 9' Applicant 7 Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201- g _ .FEE _ INFO AMOUNT DUE AMOUNT REMIT-TED CK H RECEIVED BY DATE PERMIT'NOI.� I + EH 13-24IREV.I/n5) - ] � 7/Ds Ds � v EH 14.26 J _ �r_