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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 AddressAelCity1� Lot Size T PM Owner's Name V � - Address Phone 7 �� Contractor 2da/f2- Address f C, G��xrTS License No. Phone6 2616 TYPE OF WELL/PUMP:-.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ `FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l _ INTENDED USE T:iYR OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open-Bottom ❑ Manteca ..Dia. of Well Excavation Dia. of Well Casing ❑-Domestic/Private "❑-Gravel.Pack ❑ Tracy Type of Casing Specifications �E i`l Public ❑ Otherr F F1 Delta Depth of Grout Seal Type of Grout } I I Irrigation r A._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done E Type of Pump H.P. State Work Done _ i Well Destruction ❑` Well Diameier Sealing Material (top 501 11 Deppth . , Filler Material (Below 501 —STYPE OF SEPTIC WORK': NEW-INSTALLATION Ll REPAIR)ADDITION I DESTRUCTION i I (No septic system permitted if public sewer is LLLJJJ A' S 1I } I available within 200 feet.l (' lksiallatiori will serve:' Residence— 'Commercial_ Other ` Number of'living units: -/�Number sof bedrooms !'r j Character of soil to a depth€of 3 fear- Water table depth s: 'w'SE?TEC TANKi C t.,Type/Mfg *-^-^-�"� '�' Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line ` I� -" 1 T. LEACHING LINE 'l�[ �NO.& Length of lines Total length/size .� � g FILTER BED ❑ 'Distance to nearest:. Well Foundation Property Line SEEPAGE PITS l Depth ��/ -Size Number SUMPS Cl11 Distance to nearest' Weli }lam Foundation Property Line 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: "I certify that in the performance of the work for which this permit is issued, I shall not . 1 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 certifI 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 Calif*a, ,,The applicant muu' s ns. Complete drawing on reverse side. I � T� � � .... �.. _` &666d`rie� X"""" •Title: Date: I� FOR DEPARTMENT USE ONLY �J Application Accepted by it Date L_- E_ Area or Grout Inspection by f Dat Final Inspection byJ�'/� ��l-tom, Datra� g .r Additional Comments: ❑ 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 I�. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO CASH ' r EH13-24 MEV.I/H 51 EH 14-26 ?.