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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � � � f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6751 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , rt # (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. / i Job Address Cp... , ti City Lot Size PM Owner's Name !I_lJ� ,Qlf Address Phone Phone 7.3` Contractor; Address License Na. 1 Phone '3 TYPE OF WELL/PUMP.-Vm�l� NEW WECL--CJWELL REPLACEMENT C1DESTRUCTION ❑ PUM INSTALLATION ,&/Q I Cowry;SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: EPTiC_TANIG, t SEWER LINES DISPOSAL FLO. PROP. LINE _ a� YOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS ) INTENDED USE TYPEOF WE�L'-- PROBLENIjAREA CONSTRUCTION SPECIFICATIONS O Industrial 01 _:, Operi Bottom_ . O Manteca Dia.of_Well Excavation Dia. of Well Casing 'j�bDomestic/Private , ❑ Gravel.Pack ❑ Tracy - Type of Casing Specifications , a of x+71 ,. ` 1��\ C ❑ Public ❑'Othek A Delta epth of Grout Seal Type of Grout ❑ Irrigation —Approx. j?gp h-_"_.❑Epplern_,_ Surface-Seal Installed by tttt Repair Work Done ❑ Type of Pump. SUS H.P. State Work Done ECPA 19e---- Well e----ell Destruction ❑ Well Diameter Sealing Material (top 501 3LJa G[l/7-A? ^�E1[J k Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_r Commercial_ Other i 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. TRE�TMENT PLT. ❑ ? . Method of Disposal Distance t6 nearest: Well Foundation 'Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size f .FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth I Size Number SUMPS Distance to nearest: Well. Foundation Property Line OISPOSALt 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, 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 tha 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- I tion laws of California." The applicant r equired.inspections. Complete drawing on re r A"i0e. Signed Title: Date Y' f F DEPARTMENT USE ONLY Application.!!!Accepted Date Z Area ' # I Pit or Grout Inspectio Date Final Inspection by Date' Additional Comments: i C7 Stk 466-6781 ❑ Lodi 369-36621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-f Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 f INFO AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY DATE PERMIT"NO. a EH 13;i24 .+ EH 1426 IREV.i/e 51