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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA A 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;sewageror No. 1862 for:lwell/ pump and,tFie Rules and Regulations of the San Joaquin Local Health District. Job Address �^ , L •'r` ' Ho __ City ��c�.�.� Lot Size PM Owner's Name �fldi�ss S9Phone —.2 �. Contractor - �sLo✓ Address A()-? �/� License NQA_ Phon��"�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR —OTHER ❑_—. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 D Gravel Pack' ❑ Tracy Type of Casing Specifications ❑ Public Cl Other C7 Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx. Depth l I Eastern //Surface Seal Installed by - Repair Work Done c Type of Pump _ H.P. /a_ State Work Done Q Well Destruction I-1 Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLATION I I ` REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence_ Commercial. Other '" 1 ,., Number of living units: Number of bedrooms <-!; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK t. ❑ Type/Mfg Capacity No. * I PKG. TREATMENT PLT. G1 fi Met —I sal ' Distance-to nearest: k Well Foundation Property.Li e 11L 0 8 IRS LEACHING LINE ❑ No. & Length of lines Total length/fit FILTER BED ❑ Distance td nearest: Well Foundation Pr�64Qr.J ALTF� ENI IRONMENIAL HE1;i_Ti SEEPAGE PITS I;1 Depth Size _ Number SUMPS aL ❑e--Distance to nearest: = Well Foundation Property Line DISPOSAL PONDSkT ❑ Y j I hereby certify that t 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." The applicant mut call f. all uire pections. Complete-drawing on.reverse side. - Signed X Title: Date: t INORD ART USE ONLY 4 s * Application Accepted by Date 44nrea !Z14r/' Pit or Grout Inspection by Date Final Inspection b -� ' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUV AMOUNT REMITT)D CK H RECEIVED BY ATE PERMIT'NO. INFO a.EHt3-24{pEV.1/851 EH 16.28