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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 2 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 Ordin'�No549r sewage or No. 1862 for well/pump and he Rules and Regulations of the San Joaquin r Local Health District. , 9f 761 /�W/ /t Job Address ._ .P✓� _ Cir(v/(//7i�1! UAV Lot Size PM Owner's Name Address cmc ,Tzo/ N W;. 1�.Aav9n /�GJ Phone ,� —673 Contractor._ Address License No'. Phone c� TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ~ FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS 'u — INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial (❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private'' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1. FI Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation r —.-Approx. _Depth f I Eastern Surface Seal Installed by 7�. Repair Work pone L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 50') -- Depth ' Filler Material (Below 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION V- DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) ' Installation will serve: Residence Commercial_ Other Number of living units: _r! Number of rooms f i Character of soil to a depth of 3-feet: � Water table depth' SEPTIC TANK. ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �� ) Distance to nearest: Well Foundation , Property Line f 1 r Y LEACHING LINE P- No. & Length of lines � S r g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation_�_t Property Line 02) r SEEPAGE PITS I�Depth airs r Sized W y > _� �Number��-• SUMPS ; L� Distance to nearest: `Well Z � Foundation '7 V Property Cine_/ DISPOSAL PONDS ❑ r —"'+►t I hereby certify that I have prepared this.application and that the work'tiViW.Wdone-in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dt%trict. ' _ 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 n 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 i"ided�Fshall employ persons subject to workman's compensa- tion laws of California." ( f 'A'X q f f The applicant must call for all re fired spections.-Corriplete drawing on reverse side. Signed Xt Title: [•t1 Data: s 1 FOR DEPARTMENT USE ONLY t j Application Accepted by �[ t Date Area Pit r Grout Inspection by r at Final Inspection by' �YT ate 1(� Additional Comments: P ✓ �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca'-823-7104 T" ' ❑ Tracy' 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FSE AMOUNT DUE+tAMFOU�NT REMITTED RECEIVED 6Y DATE PERMIT-NO. INFO CASH EH 13-24(FIEV.i i n 5l �� / ` �� 7e EH 14-26 f /l.J 0 -