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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. .lob Address 7 City g" Lot Size �e�� C'a'��'PM Owner's Name . ✓T 1C'_ f i 'iF c �Address -% 'f/ / r '�• )-•- Phone [�?j�� ✓�Sfir.��f; License No. ' S f Contractor's Name � v Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ' SYSTEM REPAIR ❑ OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK i ? SEWER LINES /flt e' DISPOSAL FLD.A 4� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS z=` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial/Pit ❑ Open Bottom Dia. of Well Excavation / �I •I/I Dia. of Well Casing Domesticrvae Gravel Pack ❑ Tracy Type of Casing_gV C i 000 Specifications f - -S- ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout ' s' ❑ Irrigation 110-LApprox. Depth ❑ Eastern urface Seal Installed by w Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �^- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitte 1 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 Capa ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal / Distance to nearest: WellFoundation Property Line LEACHING LINE ❑ No. & Length of Total length/size N FILTER BED ED Length serest: Weil Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 Calif nia." The applicant u call for all re 'ed ' ctions. Complete drawing on reverse side. Signed Title: t: Date: C 7�V FOR DEPARTMENT USE ONLY Q Application Accepted by Date �' `�� Area Pit or Grout Inspection Date le ^��/ Final Inspection by�W .. Data 07 r Additional Comments: 1 / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca -7104 ❑ Tracy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 #�3 9110 5uCKAcc1J1W— kFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. + EH13-24 1REV. Eli 14-26