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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Address -5-30 �� City Lot Size PM °1YSiP r Address 5 Phone Owner's Name r /s9,5 6o�,ed Contractor �7 � cr. Address O License No. Phone AS— TYPE OF WELL/PUMP: NEW WELL'[ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O 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 gv Dia. of Well Casing ❑ Domestic/Private 1,K Gravel Pack ❑ Tracy Type of Casing_ 0V Specifications I'1 Public 11 Other C-1DeltaDepth of Grout Seal n?sSrh2_5d fr1 Type of Groutd�I I I Irrigation 112!-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction C] Well Diameter Sealing Material (top 501 JV�,vtfafr WC(� Depth �!5 r Filler Material (Below 501 TF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer available within 200 feet-) Installation will se Residence _ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines �engtlh,/size_FILTER BED ❑ Distance to est: Well Foundation SEEPAGE PITS1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line _DISP SAL 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the followin "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 taws of Calif nia. ' / The applicant ust II for all re Or d i ction . omplete drawing on reverse side, v Signed X Title: 10,11, Z Date: &—.1;2 MRE&E ONLY Application Accepted by Date�r Area Pit or Grout Inspec on Date Final Inspection by Datel��f Additional Comments: r ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ Manteca 823 04 ❑ Tracy 835- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201/7 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY GDATE PERMIT'NO. # EH 13.24 IREV.1/H 51 �G1. -9-<F7 EH 14-28 7 *44M3S6W