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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 od Address }/'�ti1C� Phone Contractord<!i5 7'y (�!r Address��'O_._ Y ZZ� License No37 73e Phone3 Y-0 L TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION&9 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 /2 Dia. of Well Casing Domestic/Private %,W Gravel Pack ❑ Tracy Type of Casing '110`C _ Specifications FI Public ❑ Other 171 Delta Depth of.Grout Seal /047 Type of Grout I I Irrigation 1_�d Approx. Depth I I Eastern Surface Seal-Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �/E�CJy �i2or1 Well Destruction ❑ Well Diameter Sealing Material (top 50')-- Depth Filler Material (Below 50') �. TYPE OF SEPTIC WORK: NEW INSTALLATION ('] REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public-sewer is �. available within 200 feet") `� Installation will serve: Residence_ Commercial_ Other, C " s Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ s' Method of Disposal 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 I I Depth Size 'Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '. t 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 Di§trict. 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:"1 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 applicant must call for all r wired inspections. Complete drawing on reverse side. Signed X I Title: _Q!rd l ... Date: FQILDgPARTMENT USE ONLY y q r Applicata Accepted by data t7^t Area 1 Pit r drout I pecff& b " ` � _ Y� -Dater13'"��1 Final In by lLz� Date Z r Additional Comments: �5_ (1 O Q-e r G — ❑ Stk 466-6781 ❑ Lodi 369-3ra2lk ❑ Manteca 823-7104 ❑'Tracy 63 , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel Ave., P.O. Box 2005, Stk., CA 95201 INFO AMOUNT FEE DUE AMOU�N}T REMITTED CLASH RECEIVED BY DATE gPERM17'�NO. ♦ EH1�2aEH 13-24 tpEV.tin51 � ��Iuv Ct/ti�/ �