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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 /�� ' /[m�� ' 4,9 __ City n� Lot Size PM Owner's Name �+'� Address I`r/� Wndfr" 3.7 Contractor V/ 1#1 1 59tIAddress PW 1d� License No. �?9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public (1 Other 11 Delta Depth of Grout Seal Type of Grout_ Irrigation — Approx. De th I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. � 75 State Work Donee duy gum* 1;J 0440 Well Destruction ❑ Well Diameter 41rbl , Sealing Material (top 501 w • Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenc _ Commercial— Other Number of living units: mber of bedrooms l= Character of soil to a depth of 3 feWater table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKG, TREATMENT PLT. 17 Method of Disposal Q Distance to n crest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of 'nes Total length/size I FILTER BED` ❑ Distance to neares Well Foundation Property Line SEEPAGE PITS { I Depth Size Number SUMPS Cl Distance to nearest: Well 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 Di$trict. - I(b 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 n 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 pplicant t call or a req ed inspections. Complete drawing on reverse side. Signe Title: T 1 0 Date: nnFOR DEPARTMENT USE ONLY t Application Accepted by Date D-�'�� Area 4 Pk or Grout Inspection by Date Final Inspection by�'C�/ Da 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 1FEE AMOUNT DUE AMOUNT REMITTED CASH KIt �RECEIVED BY DATE PERM[7'N1O�. + EH 13-24[REV.I i x s) ["' �'�'�' C)•—a ! EH 14-26 J