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APPLICATION FOR PERMIT SAN JOAQU N LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. E City Ld Size PM Job Address I Owner.'..Name_ - . - A rens Phone � 3 � 1 Contractor's Na r o License No. T� 4 Phone TYPE OF WELL/PU ' P:t j NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� i OTHER ❑ DISTANCE TO�NEAREST:1SEPTICITANK SEWER LINES '° tom_ -DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE-. (TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ OpenBottom F-1MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '�5pecifications ";"_, a t El Public ❑ Other t.` El Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed,by Repair Work Done ❑ T.pe of Pump H.P. ,State Work Done t Well Destruction ❑ Well Diateter Sealing Material (top 501 I Depth-? } Filler Material (Below ,)w TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [] -DESTRUCTION ❑ (No septic system permitted if public sewer is .;. ti .. � available within 200 feet,l" Installation will serve: Residence, Commercial"`'= Other Number of living units: Number of bedrooms;^ \, s Character of soil to a depth of 3 feet:_'— ' Water table depths �Type/Mfg, Capaci No. Compartments $ E' PLT. ❑ ; .7 € Method of Disposa p Distance to nearesV �,rwell Foundation Property Line LEACHING LINE3f ❑ -N6`. & Le gth afflneS ' Total length/size M FILTER BED ❑ Distance tot e9fest: Well- Foundation Property Line SEEPAGE PITSKC-}^Depth— Size Numbers f SUMPS ❑ Dist ance to nearest: Well Foundation Property Line {DISPOSAL PONDS ❑ �"�.. hereby certify that I have prepared this applicationiand[-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:( 4 i Home owner or licensed agent's signature certifies theJollowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person insuc nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:" rtr thati in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of Californ' The appEicant �I ffoorall req. c mplate drawing on neve a side, Si O Title: FOR DEPARTMENT USE ONLY R Application Accepted by f^0 Date Area Pit or Grout Inspection by.; 1 Date Final Inspection by Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3643521 ❑ 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 95201 FEE ,INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE "� PERMIT''NO. EH 1324[REV.101531-�!41 0 +30 EH 14-26 ` _