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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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, Job Address City C. Lot Size PM Owner's Name ?1400 H45s. Address`&.4no Phone JJ OContractor Address License No, Phone TYPE OF WELL/PUMP.: NEW WELL ❑ WELL REPLACEMENT ❑ _DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �� OTHER ❑ DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL 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 0 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 C] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Materia Below 501 TYPE OF SEPTIC WORK: NEW INSTALL?yTION ❑ REPAI ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is ✓/ available within 200 feet.) Installation will serve: Residence_ Commercial_ r h Number of living units: f Number of be rooms O"r bam, Character of soil to a depth of 3 feet: C-- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation 1 I Property Line LEACHING LINE No_ & Length of lines - i Total length/size FILTER BED ❑ Distance to nearest: Well .FoundationProperty Line SEEPAGE PITS ❑ Depth Size _ f Number e SUMPS ❑ Distance to nearest: Welles 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 Healtfi'District. Home owner or licensed agent's signature certifies the following: "I certify-th t 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 workmate"s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that-in the performance ofthe work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of C "ornia." / The app lic nt mu t odl for all qu d i pe ions. C pl a drawing on raver side. { -AGSigned Title: l`^'v! _ Date: ., FA DEPARTMENT USE ONLY -�� Y Application Accepted by Date Ar a 7 - :5 � , Pit or Grout Inspection by DAte Fina nspequon by ; Date s ,pC� Additional Comments: r'� f a� 770r©6 7 JV " �/ ❑ Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ° d Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f F FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1241REV. EH 14-4-28 ti