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APPLICATION FOR PERMIT SAN JOAQUIN 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address. Z—z CityHAA1 Lot Size PM \ /Owner's Name -`� r-_ Address 1(LI 157tAIR-, APJ ,I AhJjfj Phon&Zo �i' X Contractor, ___ (,(Q_C f.�lJ�-��'�'jAd�dss Z License No. ` Phone�!�✓ u� \ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER>I`t-fW 70c 2/,,e DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _`7 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pe 1-1 Industrial ❑ Open BottomNfanteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private /y�� vel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ tt Delta Depth of Grout Seal Type of Grout ❑ Irrigation Z5_Approx. Depth ❑ Eastern Surface Seal Installed by &6&,Iuffjj Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 i Depth 7-5 _ Filler Material (Below 501 ( N TYPE OF fS4P►j�`Tlc WORK: NEW INSTALLATION EJREPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is N fi ' available within 200 feet.I s Installat on 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 fi LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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, 1 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 m t call for all required ins ns. Complete drawing on reverse side. Signed X Title: we Date: R P NT USE ONLY Application Accepted b r DateArea A Pit Grout s on by Date 8 Finall ln�pe~ciion by `^ Date7 Additional Comments: AW ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Ma teca a23-7104 7 ❑ Tracy 835- � � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201FEE f ,� v` r INFO AMOUNT DUE AMOUNT REMITTED CASS K RECEIVED BY DATE PERMIT'NO. + EH 1428 EN 3-24(REV.e/s 5] /t ..# o ?7-19