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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u (Complete in Triplicate) s`T Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. ITh s 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. RICJ/em��. Job Address City Lot Size PM Owner's Name _ / Address 0W P" V,`_? K Phone' "'E Contractor ` rql ( ►L Address a I C3,fL%LL If License No.S-d�raa �� Phone _ { TYPE OF WELL/PUMP: NEW WELL;K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK AV N t� SEWER LINES DISPOSAL FLD. f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS!" c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ,r ❑ Industrial :Open Bottom ❑ Manteca Dia. of Well Excaavav n Dia. of Well Casing 1-1lomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_„ Specifications 7 1-1 Public ❑ Other —n Delta Depth of Grout Seal cl Ty of Grout I I Irrigation � e1-.Approx. Depth I 1 Eastern Surface Seal Installed by �;h?� Repair Work Done ❑ Type of Pump H.P. State Work Done ..! Well Destruction Cl Well Diameter Sealing Material (top 501 ti Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is _ available within 200 feet.) a Installation will serve: Residence— Commercial— Other r– Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ti SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments h 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 i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line �S DISPOSAL PONDS ❑ 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 awner or licensed agent's signature certifies the following: "I certify that in the performance of the work fot 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 must call for all re aired inspections. Complete drawing on reverse side. NitSigned �C l Title: !'Z=- " Date: �� J FOR PART SE ONLY �J Application Accepted by Date �L Area Pit or Grout Inspection by Date Final Inspection by Date —Additional Comments:- 0 ommentsr❑ Stk 466-6781 ID 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT'NO. + EH1EH 3-2424 MEY.r/H5) `O–S, qV-73pL 7-�O