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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON AVE., STOCKTON, CA 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 Rules and Regulations of the San Joaquin Local Health District. Job Address J725/5 �u • City-*- Lot Size PM Owner's Name Address / `✓' u0i Phone �J may` d' P 1 Contract6r�f� Dc_ ten/ (.O _Address r /fv License No. <0 '2-Z G Phorie TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_❑ DESTRUCTION.❑l-% 4 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 � • . J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation -�' . Dia. of Well Casing LlDomestic/Private LJGravel Pack F1Tracy Type bf Casing' ' Specifications M Public Cl Other C1 Delta Depth of GrouT Seaf'" - Type of Grout 11 Irrigation _--Approx. Depth 11 Eastern Y--,,,Surface-Seal-installed-by-°•" - Repair Work Done ❑ Type of Pump H..P, ^ ^ State Work Done _ Well Destruction ❑ Weil Diameter Sealing,Material.(top-501- - Depth Fillet Material JBelowa50'i TYPE OF SEPTIC WORK: NEW INSTAL-DATION "REPAIR/ADDITION I I' DESTRUCTION I I ;No septic system permitted if public sewer is available within 200 feet.) Installation-willserve: .Residence �Commercial-___ Other Number of living units: Number oVb Broom /16 y Character of so_il..to•a-dept?t of 3 feet Water table depth SEPTIC TANK P""Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑• r r Method of Disposal . ' Distance to nearest: We 11 _-Foundation Property Line /�� 7 � I LEACHING LINE No. & Length of lines Total length/size X FILTER BED ❑ Distance to nearest: Well 14 Foundation_ /,G7 -,_ Property Line / h i SEEPAGE PITS 4.1--bepth Size Number r SUMPS Ll Distance to nearest: Well/�D Foundation l�r Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that'the work will be`(one in`accordance,with San Joaquin county ordinances, state laws,a rules a_nd•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 thispermitis issued, I shall not employ,any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the following: "l 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•af California." The applicant mlist,,call for all q 'red ' spections. Complete drawing on reverse side; Signed'X` Title: r jl'Jr Date:rlo a_ FOR DEPARTMENT USE ONLY _ a Application Accepted by Date Area 2 ^fes / or Grout Inspection by�T " ate . Final Inspection by k \ate 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 05201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 MEV.t/H 51 f EH 14-26 �� ` �� '