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APPLICATION FOR PERMIT SAN.JOAQUIN LOCAL'HEALTH DISTRICT S 1601 E. HAZEL TON 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.�TNs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. 3, - V, 4 Job Address I D-_7 i City Lot Size Y PM Owner's Name 3e=,4e�l Address r ...,- Phone C_ � � U Contractor G-F .?� Address c License No,��3 � 96f -154 °`� Phone TYPE OF WELL/PUMP: NEW WELL 1-1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION I AGRICULTURE WELL - OTHER WELL PITS/SUMPS =4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Vii% ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ,d.crt-.L- H.P, lig- __ State Work Done Well Destruction ❑ Well Diameter I t z�Sealing Material (top 501 Depth }I = Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is J", t r• available within 200 feet.) �1 Installation will serve: Residence_ ;Commercial_ Other t `' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capaclty No. Compartments PKG. TREATMENT PLT. ❑ + ',. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Lengthi of lines Total length/size �r FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ De th P SizeNumber SUMPS ❑ Distance to nearest: Well v Foundation Property Property Line DISPOSAL PONDS_. ❑ - ._ r /old I hereby certify that I have prepared-this application and that thewor wk wk ill be done iri accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San^Joaquin Local Health District. Home owner or lice nsed_agent'ssignature 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 performall&of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws of California." , i The applica ust a I for all requited pections, Complete drawing on r erre side. Sig ry' Title: Date: FOR DEPARTMENT USEONLY Application Accepted by VAi Date _ — 70 Area Pit or Grout Inspection by Date Final Inspection by Date rp Additional Comments: f y : t 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 952011 I FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. +EH 13 J24[REV.t/a 57 EH 1426 r' -