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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 7,5_-7,15 4ZE&gny2 - City ► Lot Size PM Owner's Name Q Cv6�ddress _ .�/�� Phone Contractor ddress License No. Phone 1 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTIACDESTRUCTION PUMP INSTALLATIPN_Or SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.key PROP. LINE a�lQ/E� FOUNDATION __..� AGRICULTURE WELL '�""' OTHER WELL f?—_ PITSISUMPS'� INTENDED U TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 07 Dia. of Well Casing Specifications )(Domestic/Private Gravel Pack w_0 Tracy Type of Casing p M Public e n- O her F1 Delta Depth of Grout Seal /f�tl Type of Grout I I I(rigatior� 1&: Approx. Depth I i Eastern 5uriace Seal Installed by 0 -S)ffiJ_ Repair Work Done ❑ Type of Pump _� H.P. State Work Done L�!!7"`s✓�l5d�l S Well Destruction Well Diameter 16 Sealing Material (top 501 ; Depth �L_� FilleMaterial (Below 50') TYPE OF SEPTIC WORK: OEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is V available within 200 feet., V Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to.nearest: Well Foundation Property line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well 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 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 applica!o= II re ns. Complete drawing on reverse side.. -71 Signed X Title: ..��`r Date: FO E I ISE ONLY Application Accepted by Date Area Pitr Grout I pection by a ~Date /a �/ Final Inspection by Date Additional Comments: (5 r6' /3 / ❑ Stk 466-6781 ❑ Lodi -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 95201 FEEAMOUNT DUE AMO T REMITT D CK RECEIVED BY DATE PERMIT'NO. INFO CASH +,EH 13-24 IREV.r i k 5l IN F_ 4 .V ^_,7 !k JL W-7 EH 14-26 s 1� r_ WD {.00.06 ►Ll