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E - t APPLICATION FOR PERMIT ` SAN.JOAaUIN LOCAL. HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U (Complete in Triplicate) t P I g�_ Appuca!ion 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 i9 compliance-with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R ulations of the San Joaquin ! Local Health District. l �luc� 1v fir. Jol Address '` Aw- Q/^ — ,/9Ll ll.S D YQ Lot Size PM #i gr Owner's Name r"+�j��K�� OLM6 - Address ne Contractor r+ Address e License No__t v F13 Phone s1 TYPE OF WELL/PUMP: i NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �Q r PUMP_INSlALtATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T6NEAREST: SEPTIC �A�K ' P*)QnP, SEWER LINES, - Y DISPOSAL FLD.�i°PROP. LINE ' C, FOUNDATION AGRICULTURE WELL OTHER WELL __PITS/SUMPS _ INTENDED USE TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Q ' ❑ Domestic/Private )C Gravel Pack ❑ Tracy 'Type of Casing ".0-VC; Specifications ❑ Public ❑ Other ( ❑ Delta Depth of Grout Seal Type of Grout Irrigation + --Approx: Depth! ❑ Eastern Surface Seal Installed by j Repair Work Done 11Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 E �4, Depth ' 4 r_ Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commetcial¢ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet! i Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal f # Distance to neares't: Well Foundation Property Line LEACHING LINE ❑ No. & Length of.lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth # Size Number i SUMPS ❑ 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 1 rules and regulations of the San Joaquin Local Health District. l Home owner or licensed agent's signature certifies the following: "1 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,1 shall employ persons subject to workman's compen i tion laws of California." } The appli ant ust call for all req inspections. Complete drawing r erse 'de. 1 ► i p (Signed Title: Date: 7 r { FOR DEPARTMENT U ONLY f I (, Applies fon Accepted by Date v �+ Area r o I -� Date � 7 Pit or•Grout_ Inspection Date Final Inspection by Additional Comments_: C1 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 t l FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. + EH 13-24(REV.1/6 sl ✓�� ,..r-- -" ��!(�? EH 14-26