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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 1PERMIT 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 andlor install the work herein described. This application is made in compliance with San Joaquin Cobnty Ordinance No. 549 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �_v_.S7 t ,L� R�r City Lot Siz Job Address y `!—� hone3—1 Owner's Name Wa� Address COr Contractor ` /yl Addres S'R E;lrai icense No. ,362aj Phone � k i TYPE OF WELL/PUMP: NEW WELL WELL REFIACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ,SYSTEM REPAIR © OTHER ❑ � t 6�� 'DISTANCE TO NEAREST:,_SEPTIC TANK.. .SEWER LINES• %�- - _41SPOSAL FLD/_PROP• LINE FOUNDATIONS AGRICULTURE WELL �'�'" OTHER WELL -- PITS/SUMPS ! 'INTENDED USE TYPE OF WELL , . PROBLEM AREA CONSTRUCTION SPECIFICATION 6 �/ ❑ Industrial ❑ Open Bottom Manteca •Dia. of Well Excavation Dia. of Well Ca g 16 i ` Domestic/Private Gravel Pack ❑ Tracy .. Type of Casing , Specifications � + Type of Grout�l � FI Public' C! Oth r�T� f I Delta Y Depth of Grout Seal Yp I I Irrigation A!M_-WAPTPx, iiepth I 1 Eastern-4x+' Surface Seal installed by Re air Work Done ❑ Type of Pump H.P.` � State Work Done vJ p Well Destruction ❑ Well Diameter Sealing Material Itop 50') OQ '� Filler Material (Below 50'1 pepth — \ TYPE OF SEPTIC WORK: NEW INSTALLATION ["I REPAIR IADDITION I l DESTRUCTION I I Mo septic system permitted if public sewer is 4 rJ . _ available within 200 feet.) Installation will serve:-v Residence I 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 PKC. TREATMENT PLT. ❑ I Method of Disposal Distance;to nearest: Well'`- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance':lo nearest: Well Foundation Property Line -.._—_ _ Number SEEPAGE PITS I I Depth Size ' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAUPONDS" ' '❑' — hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count ordinances, state laws, and rules and regulations of the San Joaquin Local Health DFstrict. 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 �t,callfequir ins tions. Complete drawing on reverse se.Title: G Date: Signed X F R DEPARTMENT USE ONLY Date 0 Area �/5 Application Accepted by Q Pit or Grout Inspection by �Datei7�/ Final Inspection bE� Date Additional Comments: ❑ Stk 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 95201 FE OUNT DUE AMOUNT REMITTED CASH RECEIVED BY OAT E' PERMIT'NO. IN - + EH1324 IREV.I/H sl r EH 14-26 GL o-35 b