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APPLICATION FOR PERMIT r ) SAN JOAQUIN LOCAL HEALTH DISTRICT ;' •j 1601 E. HAZEL T ON AVE., STOCKTON, CA � `` *,T�. 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address '',3P..._ City �f6CAA�/� Lotl�Size PM Owner's Name tdiy �1 A� <� L:L1RAddress A22 I E. 941',) 7T,4iVOAMA oneo • /� /� Contractor Address LSd1< I2 .P�S.yO C�.ct1 License No. Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER MMOWI-A10 11 1ue/IS 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 Dia. Dia. of Well Casing El Domestic/Private' 9 Gravel Pack C1Tracy Type of Casings�•� �f/�i Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal aS Type of Grout ❑ Irrigation 7it�pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. �-? one r� Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 /s° .j��N11�11N uJe/1.r Oepth Filler Material (Below 50`1LP TYPE OF 9EPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) LA Installation will serve: Residence_ Commercial_ 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 PKG. TREATMENT PLT. ❑ rt Method of Disposal Distance to nearest: Well Foundation . Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "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 appli n ust call fo II r quired in coons. Complete drawing_, reverse side. Signed Ti Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection b Date —� Additional Comments: �-e� ❑ 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 85201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. INFO t EH 13-24 IREV.1/855 • O Q 1 Q�/ EH 1428 A / ( �_s