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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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address 8_>WM lI b,R L4 �a N�, _ City D S7VC*-7V-1 Lot Size2o�p X300 PM Owner's Name 0/# !b ChW4&1-,2 Address i✓ Phone �- Contractor Address License No.;265�_ _ Phone_ V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-©,.---- 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal' r e Type of,Grout i ❑ Irrigation --Approx. Depth ❑ Eastern a.SurfaceSealInstalled by + Repair Work Done ❑ Type of Pump 1'' H.P. State.Work Done 1 v Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth f Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AREPAIR/ADDITION ■; DESTRUCTION ❑ (No septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence_X- Commercial Other Number of living units: —_ Number of bedrooms a Character of soil to a depth of 3 feet: --•----�--Water-tabte clepth� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE' IN No. & Length of lines >�l) '�!?� t- --Total length/size FILTER BED LlDistance to nearest: Well /06" FoundTtion *0 Property Lind'%� SEEPAGE PITS O Depths` 'Size ° ^y Number SUMPS ❑ Distance to nearest: Well jQQ Foundation Property-Line- DISPOSAL PONDS ❑ i l" 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. �J f Home owner or licensed agent's signature certifies the following:�Lcertify 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,corrnpensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the"worl ,ihich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." .-.. _�----- -T.-a----a The app nt must tail for all required inspeet'ons. Co late drawing on rev rse side. Signed Title: Date: 0 7'2�- 8� FOR DEPARTM(NT USE ONLY Application Accepted by Date Aea Pit or Grout Inspection by Date )34� Final Inspection by Date Additional Comments: j,/_ 'k - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 fnJ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4T�SL I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I INFO CASH + EH 13-24 IREV.i/H 51 /•�-� /�b ��p� 3 - EH 1428 '� ` 010 1