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APPLICATION FOR PERMIT SAN JOAQUiN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA fifR Teiephone,(209) 466.6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED F ., „(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 fog welVpump and the Rules and Regulations of the San Joaquirl Local Health District. Job Address / IX r1" ©'• j ,C.r/ � '[ J ' City Lot Size PM. +� T �_ ` Owner's Name_N " � � 4 -Address �7 P, + Phone( o Contractor 0� rr p Address License No% Phoi�i�b^ TYPE OF WELL/PUMP: NEW WELL ❑ WELL:REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR )1 - OTHER EJ TO NEAREST: SEPTIC TANK SEWER LINES n DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O.Open Bottom ❑ Manteca Dia. of Well Excavation + PL Domestic/Private E3 Gravel Pack ❑ Tracy TypeDia. of Well Casing `of Casing Specifications l ❑ Public ❑ Other = ❑ Delta Depth of Grout Seal ❑ Irrigation --Approx. epth ❑'Eastern Surface Seal installed by Type of Grout--Approx. Repair Work Done Q Type of Pump H.P. State Work Done S, Well Destruction WeIi Diameter q Sealing'Material Itop 501 _ 1 Depth_. �d { Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is V� i f Installation will serve: Residence available within 200 feet.) Commercial,;'Other,T. V Number of living units: Number of bedrooms Ii., " Character of soil to a depth of.3 feet: i 1 : 17 " J -1- —' - ti SEPTIC TANK - Water table'depth — ❑ Type/Mfg s �r �"� Capacity No. Compartments ! PKG. TREATMENT PLT. LJ Method of Disposal Distance to nearest: WellFoundation 4 I ; Property Line LEACHING LINE ❑ No. & Length of lines "` Total length/size FILTER BED ❑ Distance to nearest:•''` Well - d Foundatioh. Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well. ._Foundation - r DISPOSAL PONDS% ❑}. _ Property Line -- I hereby certify that I have prepared{his 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.", I The applicant must call for all required'inspections. Complete drawin on reverse side. Signed X_ ' Title: Date: C 1 FOR EP T 'ENT USL Application Accepted by y a< `' ` �( Date Area l Pit or Grout Inspection by r Date Final Inspection by � Dat ' Additional Comments: 62 I ❑ Sic 466-6781 ❑ Lodi .369- 1 .❑ Mant ca 823-7104 ❑ Trac 835- y �1 Applicant- Return all Copies to: Environmental Health,Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�..-_'`Q�(/(�/!J T ' FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT-NO. f ♦ EH 1 -24(REV,i/H 5) a 4 ,� EN 144-28