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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 (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 `5 k City Lot Size PM _ Owner's.Name Addressca</J�y�L�iPhone Contractor Address T .f icense No.774fz Phone - TYPE OF WELL/PUMP: W WELL / WELL REPLACEME DESTRUCTION ► PUMP INSTALLATION I— SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�/ PROP. LINE ,'�j} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA; CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing GI�Domestic/Private F) Gravel Pack _171 Tracy Type of Casing. Specifications 17 Public n Other F1 Delta Depth of Grout Seal Type of Grout. I i lirigation 1,P&..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. Work Done /! e S Vel Well Destruction Well Diameter .. Sealing Material (top 50) e 3� Depth Filler Material (Belriw 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION{ ) (No septic system permitted if public sewer is available within 200 feet.) Insta will serve: Residence_ Commercial_ Other Number of living u ' ' Nu}rtber of bedrooms Character of soil to a depth o % Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ t .—Method-of Disposal Distance to nearest: ° .Well- ation Property Line LEACHING LINE ❑ No. & Length of lines Total leng FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth_ Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 JoaquinLocal 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;Cabfornia." ,�rr The applicant m call for all'fequ, nspe ions. Complete drawing on rev a side. �" t Signed X Title: c /Y - __ Date; FOR DEPARTMENT USE ONLY Application Accepted by 4 + f Date lv O Area Pit or Grout Inspection by / L Date Final Ihspection by Date Additional Comments: iLGf dG , _ Gi� ❑ Stk 466-6781 C1 Lodi Lodi 369-3621 , Manteca 82Y7104 ❑ racy 835-6385 !y 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 RECEIVED BY DATE PERMIT'NO. aEH114-2e 3-24{REV.r/n51 ''Io ®Q EH sir.. � '= •_�. �. .� �3 �� V)JE v V+ q_1-�d(a PUN1 A