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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON 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 ? J J Job Address /'�t/��' City � f Lot Size PM t Owner's Name 717—W r A A/dO/AddressPhoner ' Contractor C�Ie. r1 L Address Z G Nell Phone 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑t SYSTEM REPA9R ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /J-g SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL '� —OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC O /IP ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tori* Dia. of Well Cass ❑ D estic/Priv_ate ravel Pack' ❑ Tracy Type of Casing Specifications ubfic f-1 Other 1 ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by4-M Repair Work Dona ❑ Type of Pump x H.P. State Work Done_ J Well Destruction f�Well Diameter Sealing Material (top 50'1 V Depth'_*�__.-,_` _ Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I Wo septic system permitted if public sewer is \ ¢ available within 200 feet.) 1\t\\ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4 Water table depth j SEPTIC TANK ❑ Type/Mfg F Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property.Lina LEACHING LINE ❑ No. & Length of lines x- Total length/size -FILTER BED ❑ Distance toynearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size ' Number ts SUMPS 0Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and rules and regulations of the San Joaquin�Local Health Di%trict. = Home owner or licensed agent's signature certifies the following: L-I certify that in the performance of the work for which this-permit is issued, I shall not employ any parson in'such manner as to become subject to workman's compensation laws of California." Contractor's 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 applicant t c I Jfr?eq&Vpx ions Complete drawing n r erse e. - Signed X Title: - - FOR DEPARTMENT USE ONLY � Application Accepted by Date I ��yy� Area Pit or Grout Inspection by Date_ Final Inspection by 1 /" ` Date 36 f 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 s AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. t r..EH 13-24(REV.t/n 51 4 �� EH 14-26 r (J i i