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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 s wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1!2. � j��" � (u jFt Q' \ } o p ZCV-O 2- Job Job Address &W-laIL11whIlCity 1� Lot Size l ce-rZ PM i Owner's Namel .L�f _ l J�1< �5, Address /7,4:;o55 --1 - d Phone 0709, 20 YY1,� � i tCont actor— ' Address 1� 802A W)A License No. a/ L Phone- - -TYPE hone-- TYPE OF.WELL/PUMP:-, NEW WELL.. WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION MSYS7 M REPAIR 171OTHER ❑ r �,, -- r I DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES bpd DISPOSAL FL PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELLL-bVQ_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CDS .4 _ ❑ Industrial ❑ Open Bottom Ll Dia. of Well Excavation Dia. of Well Casing ' Lt-iEllo—mestic/Private E+3 nivel Pack ❑ Tracy Type of Casing Specifications f" F] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grou I i Irrigation Approx. De th I 1 Eastern Surf a Seal Installed by Repair Work Done CS Type of Pump Z,/5CO H.P. State Work Done Well Destruction ❑ Well Diametef Sealing Material (top 501 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence I. Cbmmercial_ Other Number of living units: Number f bedrooms ! i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capaci- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: W Foundation Property Line SEEPAGE PITS I 1 Depth Size Number i - SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ i I b I 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 td become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I 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 u trri call for all require inspectigIns, Complete draw' g on reverse side. r Signed XData: FO DEPARTMENT USE ONLY Application Accepted by Date ArFL4y Pit or Grout Inspection by C Date 0Final Inspection by Datev Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'No. r EH 13-241REV.v/Hsl CS Ute . ay y S. S -lf-� EM 1020 I I l