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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , A (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. 1802 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, C Job Address City Lot Size PM f 1 / j A Owner's Name11d�r h C `t` —Address L � ¢ Phone Contractor Cj� � �Y '� Address 3V (7.9- l�^P License No. 3�! s Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANW. SEWER-LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL c OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICVJS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExDia. of Well Casing Domestic/Private ravel Pack racy Type of Casing cavati Specifications 11W E] Public ❑ Otger y 1:1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation /'IV_Approx. Depth ❑ Eastern Surface Seal Installed by `P Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter��— Sealing Material ftop 50'I ©© �J Depth U .I��[.�= Filler Material (Below 50') TYPE OF SE WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R a_,Commercial_ Other Number of living units: Num Orris Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ T e/Mf _ YP 9 city PKG. TREATMENT PLT. ElNo. Compartments i Method of Disposal Distance to nei arest; Well Foundation Pro Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth { Size Number SUMPS ❑ Distance to nearest: Well •Foundation Property Line DISPOSAL PONDS ❑ j 1 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."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." t The applicant m i for all q d nspections. Complete drawing on r1yerse side. I Signed X Title: Date: F FOR DEPARTMENT USE ONLY Application Accepted by Date C" 0— Area Q� Pit or rou Inspection by I Date—•- rte— Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � i rt FEE INFO AMOUNT DUE. AMOUNT RE ITTEp CASH RECEIVED By DATE PERMIT'NO. + EH 18-24(REV.1/a alt 6g6k;�= 1,7—�0 EH 1 -28 (J r -