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r APPLICATION FOR PERMIT 4� l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 .E rt PERMIT EXPIRES TYEAR FROM DATE ISSUED' (Complete in Triplicate) i 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 welllpump and the Rules and Regulations of theSan Joaquin Local Health District. I SERV l[C Es i�,�. � - City • Lot Size PM Job Address-Y-40 Address Phone Owner's Namey+ n"u p j 3 - 4 c ff Contractor fi �� D p J(�"��Q,` �II Address �` License No.1G.2 Fh,ne41447�� "''� TYPE OF WELL/PUMP: ;I NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAbL'i4TI0N ElSYSTEM 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing (1 Specifications ❑ Domestic/Private Gravel Pack- __-p Tracy .fir Type of Gasing µ __.P,._ 1-1 Public Cl Other ❑ Delta Depth of Grout Sea! �" ' Type of Grout _ leIrrigation I _App(ox. Dee th I/1 Eastern Suri e Seal Installed by r- _- Repair Work Done L' Type of Pump / d�� H P Jr� - State Work Dane Well Destruction ❑ Wh0'1 ell Diameter Sealing Material Itop 5 Depth Filler Material I9elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t i DESTRUCTION I I INo septic system permitted if public sewer is� } available within 200 feet.) Installation will serve: Rellidence___ - Commercial_ Other Number of living units: Number of bedrooms } I Character of soil to a dep41'th of 3 feet: Water table depth SEPTIC TANK ❑ 1-Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 'j, : " Method of Disposal Distance to nearest: Well Foundation Property.Line 4 1 ' LEACHING LINE ❑ No. & Length of lines ; Total length/size FILTER BED ❑ Distance to.iearest: Well Foundation " Property Line • � yF SEEPAGE PITS t II Depth_ ' s Size Number SUMPS .y Gl Distance to nearest: Well Foundation I Property Line DISPOSAL PONDS ❑IN 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 thalSan 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 applicantu ll for all required,inspections. Complete-drawing_on reverse.sidii.__- --' - � -- -- f Signed X I" itle: �'r - Date: DEPARTMENT USE ONLY nX Application Accepted by Date "� Area k Pit or Grout Inspection by Date Final Inspection by O Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO" INFO �.EH 13-24 MEV.t/n 5) EH 14-2e Ilf _