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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA R E C E 1 V E D Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Jul- (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heNVIRrein c�ONMEfNTAL HEALTH made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well/pump and the Rules and Re,gP\ Of the San Joaquin 9;�$b( Ition is Local Health District..�7 Job Address / 0S— zc JC City Lot Size_ PM Owner's Name Cay 0, �o� Address �2/ �!//�r f C—5-.714C-61 ST �� , � Phone � a Contractor's Name C�N, �tibr�yv��w License No. a6 � Gi'�d �� 7L7 3,�5 TYPE OF WELL/PUMP; NEW WELL Phone WELL REPLACEMENT C DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS 11 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private J$Gravel Pack ❑ Trac — Dia. of Well Casing �(Public CJ Other V Type of Casing Specifications ❑ Delta Depth of Grout Seal ❑ Irrigation --Approx. Depth ❑ Eastern Type of Grout Surface Sea! Installed by (� Repair Work Done ❑ Type of Pump_ H.P. I a CJ Well Destruction ❑ Well Diameter 20 11 State Work Done Sealing Material Itop 50') R) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septicsystem per within 20mitted if public sewer is Installation will serve; Residence_ Commercial— Other available wit0 feet.) SZ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �� ❑ Type/Mfg Capacity— No. Compartments fp PKG. TREATMENT PLT, ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED LJ Distance length/size Distance to nearest: Well Foundation � Property Line SEEPAGE PITS ❑ Depth Size ` . SUMPS Number ❑ 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 District. Hort o r r e�i�sl csignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emp y�p�� e�6e iQ eoome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ' certifies thl7d§%W*LSl4 *VVn the performance of the work for which this permit is issued, I shall employ p y persons subject to workman's compensa 11 tion Ia,1,A f I WA. CA. 85050 The applicant must call for required I spe ions. omplete drawing on reverse side. G Signe Title: S%f tk � 7 Date: p R DEPARTMENT USE ONLY C�cy Appk ion Accepted by Date — C� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 11 Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BYDATE PERMIT"NO. r EH 13.24(REV.10183! EH 1428