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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. L /� Job Address 0 _�_We'�7C�� ' A V e Ci 9h �G � T 3 L.i ty Lot Size PM I Owner's Name§P • /r Sia ►J Address lo0 IF.wellley;vx. Ave Phone 2_3 9—2'7 b?Q Contractor's Name License o. / Phone TYPE-OF WELL-/PUMP:- -- NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ i SYSTEiM REP ❑a .� OTHER/El DISTANCE 70 NEAREST :SEPTIC TANK Z10 SEWER,CINES .__` �_a DISPOSAL-FLD. � g-0 OP:-LINE�� rh FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L �t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav t'on Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TYeP of Casing G Specifications � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done M011'e— Well Destruction ❑ Well Diameter Sealing Material_(top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public seweris ..,available within 200 feet.) Installation 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 Capacityi y No. Compartments PKG. TREATMENT PLT. ❑ ',,.: Method of Disposal Distance to nearest: Well Foundation Property Line r " 1 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 ❑ hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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." Contractors 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 applicantus all foA re ired i 'on mplete drawing on -reverse side. Signed V pe Title: Dater f OR DEPARTMEN USE ONLY Application Accepted by Date — 2/ Area Pit or Grout Inspection by Date .Final Inspection by Date 4� i Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental lleaTth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. . EH11- 324IRE4I.10l�31 � s � fS �9�b } EH 1426 VV -b