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APPLICATION FOR PERMIT SAN.JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 j PERMIT EXPIRES 11YEAR 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 fof well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O • 6 6, �M—b City leD Lotl,Size ; PM Yt G�: aL Owner's Name O ` ) ddress Phone 62. Contractor C L Lek (A)ftl,Address -24�4 r' ! nse No, V Phone 4 6" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION © i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS '_ INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ; industrials cvation» ❑ - . ` Dia.of Well.Casi ig ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1 F1 Other ❑ Delta Depth of Grout Seal Type of Grout T I I Irrigation Approx. Depth i I 1 Eastern face Installed by t Repair Work Done ❑ Type of Pump ._. _ H.P. State Work Done Well Destruction ❑ Weil Diameter,' Sealing Material (top 501 Depth R Filler Material (Below 50') 1 V� TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRJADDiTION l l DESTRUCTION { I (No septic system permitted if pudic sewer is �+ available within 200 feet.I a Installation will serve: Residence_-40 Commercial Other . Number of living units: €!> Number of bedrooms r Character of soil to a deptH of 3 feet,.' Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ a Method of Disposal =s < Distance to neatest: Well Foundation Property Line { LEACHING LINE ❑ No. & Length of lines _ Total length/size .^tr FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number t SUMPS 0 Distance to nearest: Well Foundation Property Lime r� DISPOSAL POPQS ❑ { I hereby cerf th t I have prepared this application and that.the work will be done in accordance with San Joaquin county>ordinances, state laws, and rules and m ulatio s of the San Joaquin Local Health District. r Home owne or Ii nsed nt'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 p. so in suc anner as to bec suN o workman's compensation laws of California."Contractor's hiring or sub-coritracting signature certifies the folio g: "I rt y th in the mance the work for which this permit is issued, I steal!errlpl`oy>persons subject towork'man's compensa- tion laws of nia." i The applica t t a r II a ed i s. C plate drawing oV rev se side. JrGcL Signed X Title: Dater � � FOR DEPARTMENT USE ONLY 4 Application Accepted bys'f � Date - Area ' Pit or Grout Inspection by Date Final Inspection by ,d� /� D"ate a Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 838-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-21(REV.1/N 5) EH 11-28