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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZEL T ON AVE., STOCKTON, .CA R 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 Q 1�- � - ` ArapIt C& City/Va�� Lot Size ��C3 PM Owner's Name "�277 / dQ/' Address I e �` 2 L • �7 C�CxC- Phone Contractor G w P Address k 49 Y; License No. Phone_ TYPE OF WELL/PUMP: . NEW WELL L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ti--❑ OTHER. ❑ % ," A DISTANCE TO NEAREST: SEPTIC TANK h SEWER LINES i' ¢ DISPOSAL FLD. PROP. LINE FOUNDATIONt AGRICULTiJRE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA -TFON-SPECIFICATION S ❑ Industrial ❑ Open Bottom 0_I�Aanteca> Dia. of We(1'fixcavation .: Dia. of Well Casing.. ❑ Domestic/Private Ll Gravel Pack ❑ }� �.7 Type f Casing Specifications F] Public ❑ Other I 1-1 Delta pth of ro t Sea Type of Grout. _ 11 Irrigation _-Approx. Depth 11 Eastern y - Repair Work Done ❑ Type of Pump H.P. # State Work Done t Well Destruction F0 II I Rt ) th _ Filler Mateial —.- k, TYPE OF SFMii ORK: OEft4NSTALLATION {1 REPAIRJADDiT1bJI DESTRUCTION l I INo septic system permitted ii public sewer is ri available within 200 feet.) } Installation will serve: Residence mmrcial_ Other i t`i j q Number of living ))nits: Number of bedr`o 3 / Character of soil to a depth of 3 feet: } table depth " SE TIC TANK P Type/Mfg L Capa-at N - X70.r mpanments �� "4 = +•• M t d of Disposal PK . TREATMENT PLT. ❑ -- r poral M —"" Is an ¢`to n rest: uudationProperty Lines f CHING LINE 0 No. & Length of lines � f �otal4engtW.size FI TER 13F Distance to nearest: Well ,�'z e`fir EPAGE PITS l 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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." i The applicanImAst call for all require Hsps Ions. Complete drawing on reverse side. p Signed X Title: Date: } OR DE.91ARTMENT USE ONLY Application Accepted by Date fJ _ ea Pit or Grout Inspection by I Data Final Inspection by Date'-� .Additional Comments: ❑ Sik 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 95241 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +.EH 13.24 1REV.+/N 51 EH to-26 r