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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601,E HAZEL C N'A`UE,,_ STOCKTON, CA .A �1 Telephahe (209)'466-6781 � � r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '< C. (Complete in Triplicate) 4 HALtH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work ��n�e (�f �ication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RultlrS W) Local San Joaquin I Local Health District. fj. ` F 1�� Job Address _ / �C�-^-��F� n� City Lo�tjSize PM Owner's Name Address �ZI /CIA he - & I Phone el-31-AC210 Contractor L Address 14"130–A60Z /!92.7—License No.fb 2 3 zt3'Ptione TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK. SEWER LINES DISPOSAL FLD. 'PROP,. LINE' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/jSUMP,.S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O DomesticlP�i�ate�`g.. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public 1-1 Other 171 Delta Depth of Grout Seal Type GV Grout I } Irrigation ..Approx. Depth , I Ea tern Su�ace Seal Installed by fir, . �.t _ r� Wel(l Repaihllo k.Done of Pump H.P. State Work Done Well Destruction Diameter Sealing Material (top 50'1 "till _3,..✓ 'Depth Filler Material l6elow 50'1 '-- - TYPE OF SEPTIC WORK:�rNEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted•ifipublic sewer is ^� available within 200 feet-1 1 Installation will serve:1 Ab'sidence_ Commercial— Other i Number of living units- '� Number of bedrooms Character of soil to a Ilepth of 3 feet: Water table depth SEPTIC TANK ❑ Type/NI Gapacity `""'"""'Nb:Citltigartmfs'; I PKG. TREATMENT PLT. ❑ 1 yg ^, Method of Disposal Distance to nearest: Well � Foundati Al � 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 'f SUMPS L7 Distance to nearest: Well Foundation Property Line r b DISPOSAL PONDS ❑ 1 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 regulationsof th San Joaquin Local Health Diltrict. f Home owner or lice agent ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pers in such mann r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol wing: "I certify at' the or c f or for ich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ealiforni6. • The applica t must r all quire n e rawing on /r side f/ # Signed Titie: 'i `" 'P Date: FOR DEPARTMENT USE ONLY s Application Accepted by Date ��'��i�' Area Pit or Grout Inspection by Date Final Inspection by Date1�? s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM '_NO INFO +.EH 13-24 IREV.1/"5) EH 14-28 �'~.�