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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZEI✓T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED II 4 "• 7' (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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for Local Health District. well/pump and the Rules and Regulations of the San Joaquin 4 Job Address to City fA Lot Size V PM Owner's Name AAVQ� R Address '� —� JJ � Phone Contractor 1j -L t Address46-6 License NoPhon TYPE OF WELL/PUMP: NEW WELL EIWELL REPLACEMENT ❑ DESTRUCTION ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E}J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing p C�Tracy '– Type of Casing f'l Public f� Other Specifications . F Delta Depth of Grout Seal I ! Irrigation "" Type of,Grout •` J �.-Apprbx, pepth" "I"I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump y p State Work Done_ Well Destructioni9.� Well Diameter Sealing Material (top'50') yGy�/,�3 !' Depth Filler Material !Below 501I�f TYPE OF SEPTIC WORK: NEW INSTALLATION [.] REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is ' Installation will serve: Residence— Commercial— Other available within 200 feet.) [� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ i►� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Lf.,, No. & Length of lines FILTER BED '' Total length/size ❑ Distance to nearest: # WeII Foundation Property Line SEEPAGE PITS I I Depth ----L--Size Number SUMPS ' L� Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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'agant's signature certifies the following: I y employ any person in such manner as to become subject to wo kman's clompensation laws of n the Califorrnia."Contractor'snce of the work forrhiringl or sub-cont act ngpermit is issued, lsignaltunot rre 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." 11 The applicant must call for all required inspections. Complete drawing on re arse side. Signed Title: t Z� Date: F0WOEPARTMENT. USE ONLY Application Accepted by `ffe Date Area Pit or Grout Inspection by Date Final Inspection by Data w Additional Comments: 0,0.U r L) Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 LI Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE 'PERMIT'NO. + Eli 13-24(HEV.t i n 5) ij,,Qrt.) EH 14-26