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s APPLICATfON FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRICT p • SA 1601 E. HAZE I ON AVE., STOCKTON, CA , Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED MAY t 9 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thX_WyRQWRN1AW.EASsrappIicaTion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulPE2Mff4tfl1aV1GEbthe San Joaquin .i Local Health District. Job Address '7City Lot Size 0, CPM .�lJ QihC{? �Y Phone Owner's Nam Address f _..�- -, Contractord�/�L ��-�d Address 4'ZAa_� License No�lL_Phone 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 ilia. of Well Casing j gebomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ti. Specifications ��K F1 Public l l Other i1 Delta Depth of Grout Seal R Type of Grout _ I I Irrigation _Approx. Depth I i I Eastern Surface Seal Installed by � Repair Work Done '4 Type of Pump H.P, ! - "sj r State Work Don A14,!--,C � I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 � t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION-I.1'(No`septic'systerriwpermitted it public sewer is N # available-within'200 feet.) 9 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: '' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r 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 Cl Distance to nearest: Well Foundation Property Line 1 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::1I 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." Contractors 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 comp sa- tion laws of California!"J The applicant must tail for all required inspections. -plate drawing on reverse side. , r Signed X �� Title: Date: FOR DEPARTMENT USE ONLY J� Application Accepted by Date Jr�" Area Pit or Grout Inspection by Date Final Inspection by Z Date 59, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k' 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 r.EH 13-24(REV.i/H 5) `I 1 EH 14-26 D c tlI ' 1.