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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.', STOCKTON, CA l Telephone (209) 466-6781 l !i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I�! (Complete in Triplicate) I 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 Disti�,; - - Job Address ,..+ Ci Lot Size PM Air Ow A;zn N .i Z � Address � � -�I�/�/r>>.Q�f PhoneI JuI✓ Addressd464-x�icenseaV6 N Phon�Sr TYPE OF WELL/PUMP: i; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATIONr SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI 'iTANK SEWER LINES DISPOSAL FLO. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE "IrxPE O �❑ Industrial r] Open'Bottom 111 Manteca Dia. of Well Excavation Dia. of Well Casing 00 JDomestic/Private ❑ Gravel Pack I] Tracy Type of Casing Specifications �❑~Public ❑ Other a O Delta Depth of Grout Seal Type of Grout ❑ Irrigation ": Approx. De 0 Eastern Surface Seal Installed by I r� Repair Work Done ❑ Type of Pump, H.P. <3 State Work Do Well Destruction ❑ Well Diameter; Sealing Material (top 50'! ,4 —Depth � Filler Material {Below 501 .TYPE 4F SEPTIC WORK:YNEW_ INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewers !— available within 200 feet.) Installation will serve: Commercial_ Other Number of living units: Number o !ff SCharacter of soil to`wdepth of'3-feet:- Water table depth t` EPTIC TANK Cii Type/Mfg..' . No. Compartments PKG. TREATMENT PLT. ❑ II Cn 'ar�e � Method of DisposaDistance tost: Well Foundation 7!!fProo�pe LEACHING LINE ❑ �� No. & Length of,1lines 1 '..a Total length/size I FILTER BED ❑'1j Distance to nears: ) We'l'l I Foundation Property Line ' 4 SEEPAGE PITS ❑ Depth SIS e�� Number 'f SUMPS ❑41 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑qi I 1,hereby certify_thatThave 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. t _ f lYt, l p� 4 Home owner or'licensed agent's signature certifies the following: "I certify that_in th_e performarice'oUthe-work.for.which this permit-is-issued;I•-sKall not employ any perso such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature cert'rffes the folio�in :"I certify that in the performan a of t r'wo`rk•f which this permit is isbuedR('•shall employ persons subject to workman's compensa- tion laws of`Ca or ia." 11 ;. The_applica us fl-for- II-req a nspe tions Co lete-d ng-on side. Signed PtTitle: Date: e qfi , w I! F R DEPPLRTMENT USE ONLY ! Application Accepted by Date Area t Pit or Grout Inspection by Date Final Inspection by OV-c (Date LZ l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ 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 FEE to INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY f DATE PERMIT'NO, + EH 13-24)REV.i i e sf EH 14-26 ___1