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C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �7 ---.--- (Complete in Triplicate) e95– 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 we /pump and the Rules and Regulations of the San Joaquin Local Health District. j✓✓L Job Address / ' Q l7 ` o= City =41 1/, Lot Size G- PM Owner's Name �� 'Y e Address l— 4 /9 �� Phone 6� �f Contractor 51�_-" Address License N0.1? �s 4 y Phone�� 3 TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMEN DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 47 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL"FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v INTENDED USE V TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial IDOpen Bottom ❑ Manteca Dia. of Well Excavation t 4 Dia. of Well Casing EI Domestic/Private El Gravel Pack LI Tracy Type of Casing l Specifications {h FI Public f-1 Other l:l Delta Depth of Grout Seal Type of Grout -a Irrigation _..Approx. Depth ,l Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump7_✓�A l�1� H.P. State Work Done _ J Y ` Well Destruction ❑ Well Diameter Sealing Material Itop 501 _ Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 flE I N I T TI I R ftfe m permitted if public sewer is 200feet.) _ ? Installation will serve: Residence Commercial_ Othe i O Number of living units: Number of bedrooms iE may haya �xplred W1k11VIF�te Character of soil to a depth of 3 feet: L �I� tl I r table depth SEPTIC TANK ❑ Type/Mfg work halnc ag, r�t�:��?�?€ rinemeoteclompartments PKG. TREATMENT PLT. ❑ - by [nv!rC�(�n_-.:La1 Health Di`}I J od of Disposal Distance to nearest: Well ! Foundation Property. ine LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line dd .1 SEEPAGE PITS l I Depth Size _ Number SUMPS Cl 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 Joaquin Local Health Diltrict. 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, l 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 app icant mkAstcall for all require s i o1plete drawing on reverse side: Y Signed Title: —Ala -7 e`- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` u i� __ AreaOp Pit or Grout Inspection by Data Final Inspection by Date Additional Comments; - ❑ Stk 466-6781 ❑ Lodi 369-3 ❑ Manteca 823 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C JL RECEIVED BY DATE PERMIT NO. INFO r-6 ( %� +.EH 13-24(REV.I 1 N 5) �5)! !�a ff ..� W EH 44-2e l e