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APPLICATION FOR PERMIiT4 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. / 27 ` Job Address City " / Z` 11 rot SiZe� ~ PM Owner's Name ' � s . LL .Ni G � Phone��ev C icenseContracto Phone C y l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT JC DESTRUCTION ❑ PUMP INSTALLATI i ❑ SYSTEM REPAIR ❑ ---_OTHER-i--•---- DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD.« PROP. LINE �V FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack- 0 Tracy Type of'Casing 'Specifications /G ❑ Public ❑ Other ❑ Delta Depth df.Grout SealR Type out El ---Approx.Approx. Depth tern Surface;Seal Installed by_ ��. Repair Work Done ❑ Type of Pump H.P. z2 State Workrk-Done Well Destruction ❑ Well Diameter - Sealing Materiai-(top 50') Depth p Filler'Mate'r'ial (Below 50'j' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted if public sewer is available within 200 feet.) 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth - Size ` Number SUMPS �- .0 ❑ Distance to nearest: Well Foundation Property Line a r 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 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 applicant mus Call for all required inspectio mplete drawing'on reverse side. Signed �L Title: � � Date: FOR DEPARTMENT USE ONLY Application Accepted by Date - Area Pit or Grout Inspection by / Date /V' 0 r Final Inspection by Date �. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 dik-ty I>fgRf5 l5& (gr IC,AT16iy. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED 8Y DATE PERMIT'NO. + EH 13-24(REV.S785f A ��-y3