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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N, (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. r'<' Jul) Address _1-0,0 / G[�a4. p "A7f_ + Cit ` PM Size d Owner's Name = D A R&eIZNCeAddress sz Phone Contractor �/ Address "License No. �^—'� Phone '"`�� \7,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/SUMPS _ IhINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Privatd ❑ Gravel Pack ❑ Tracy" Type of Casing' " :."' Specilications- I ,F 1-1 Public R Other f F7 Delta Depth of Grout Seal . Type of Grout ,w _ _ I i Irrigation _Approxi Depth I 1 Eastern Surface Seal installed by Repair Work Dane ❑ Type of Pump H.P. r State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') YPE OF SEPTIC WORK: NEW INSTALLATION l'] REPAIR/ADDITION I I_DESTR TIO_N" (No septic system permitted if public sewer is �.- vailable within 200 feet./ Installation will serve: Residence CommercialL ` �`Other 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 PK, . TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I - LEACHING LINE ❑ No. & Length of lines Total length/size 'i FILTER BED ❑ Distance to nearest: Well Foundation Property Line ;EL 5 ILII SEEPAGE PITS 1-1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 1 he certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rule`s and regulations of the San 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- r tion laws of California." j Thel applicaniAust call for all required ins ch ' s. Complete drawing on reverse side. i .41 i Signed Title: Date: ��. F R DEPARTMENT USE ONLY ) Application Accepted by Are Date ' a j Pit or Grout Inspection by Data Final Inspection by Date 'il d Additional Comments: �.1 G , � f� ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 d� --�' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT"NO. I i EH 13-24 f EV.I i n 51 `� � EH 14-2a