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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. <Z<7 , ae D Job Address Q SJ E Lme- Cr �t �. City �`�"v� Lot Size PM Owner's Name � ' ""� "w"t`L�. Address 125WO g `)'Le TCee '"�� / Phone �,/ --.t Contractor's Name �� 1 �- License No. 3 � 1 � � Phone Ito TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES — _ SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done APK4Oty.� Well Destruction ❑ Well Diameter Sealing Material (top 501) 1 Wtlk Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \ Installation will serve: Residence— Commercial— Other available within 200 feat.) 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 0 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines ' Total length/size �r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Waif 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. 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."Contractors 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." 0 The applicant 1st call or all req ired ins ti s. Complete drawing on rev se side. �j(r l rOJ Signed X Title: Date- Application DEPAR ENT USE ONLY Accepted by Date �`�4� Ar,, Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUREITTED NT DUE AMOUNT M INFO r,CgKg}I RECEIVED BY DATE PERMIT'NO. +EH 13-21{REV.tel831 , UU `� EH 1428 r�rY �]