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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) IN� d /�eC.� A� 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 ��/ 145s�qYcfq9 �c. Loi Size � ZPM Owner's Namesl��^�� `-'-�fes" Contractor,Q Address fir!s� `cense No. fi e o TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ©--' REPAIR ❑ --r. 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 ❑ Indus pan Bottom ❑ Manteca Dia."of Well Excavation 47 Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications J4 r ❑ Public El Other ❑ Delta Depth of Grout Seal Type G out ❑ Irrigation .2$7&pprox. Depth ❑ E tem Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADI5MONd❑f 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS T❑ , hereby certify that 1-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 far which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant mus all f r all required inspections. Complete on reverse side. C� Signed I itle:_/a�i _ Date: or FOR DEPA MENT USE ONLY Gf p Application Accepted by ��,,tt Date Pit or-Grout Inspection by 4 Date final Inspection b Date f /� Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 8.23-7104 ❑ Tracy 835-6385 Applicant- Return all dopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. ` INFO CASH �S A tom$6 +EH 14-2A[REV.s/b5) � '�- �� gs— EH 1426