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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -1601 E. HAZELTON 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. Address ddress . City �5ize AW-�'� PM Owner's Name Address3 Phon Contra?44-19'0 Addressis Z.� 5 License (vo,� �7, Phone �� l p TYPE OF WELL/PUMP: NEW WELL 11WELL AREPLACEM�EN;�� DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTICJANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial y Industrial ❑ Open Bottom ❑ Manteca Dia. of WeEI Excavation Dia. of Well-Casing 4� ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications" ! FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_= I 1 I I Irrigation _--Approx. Depth { I Eastern Surface Seal lnstalled by' Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well piameterSealing Material (top 50') Depth filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I- REPAIR ADDITION DESTRUCTION ( I (No septic system permitted if public is�j"�� W available within 200 feet.) + Installation will serve: Residence_._ Commercial ether � Number of living units: —/— Number of bedropps Character of soil to a depth of 3 feet: . Water table depth 1� SEPTIC TANK ❑ T e/Mf �^" R yp g� Capacity_ No..,Compartments PKG. TREATMENT PLT. ❑ - �I • Method of Disposal Distance to nearest: Well Foundation 4 Property Line LEACHING LINEo. & Length of liries -- _ ` Tal length/size r ` FILTER BED ❑ Distance to nearest "Well _.- Foundation„ - Property Line sr_ SEEPAGE PITS I I Depth Size +' Nurr)ber SUMPS Distance to nearest: Well_ Z 9Q 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 Di$trict. 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 California." ` I The applicant must c I or all req r d ins ctions. Complete drawing on rever e. ! 9 Si hed X Title: Date, OR DEPARTMENT USE ONLY Applica � Acce d by � I Date 2 2—" Area. �1 r ut fns Ion by Date 2-2 Final Inspection by Date wC Additional Comments: EI 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 95291 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"ND. INFO CASH EH 13-24{REV.li+t51 �� EH 144-26 Q)