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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address J/ City, _ 1 Lot Size PM Owner's Name Address Address Phone - ��'o yYlf ��,1_Q ddres-s -� �� -- - f - r lo (/�(_'5J /Jr�( License-No.-- ---Phone S TYPE OF WELL/PUMP: NEW WELL Pg_ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION it ^' SYSTEM PEPAIR ❑ /OT/HE,R ❑ DISTANCE TO NEAREST: SEPTIC TANK _f=7c� SEWER LINES DISPOSAL FLD.L-Y_{��"PROP. LINE, X/d r FOUNDATION _,-._ � AGRICULTURE WELL ' THER WELL 0PITS/SUMPS "42_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W-1110mestic/Private gavel Pack 171Tracy Type of Casing G 7 P.0 Specifications 71 Public F1 Other L-1 Delta Depth of Grout Seal Type of Grout i I Irrigation _..Approx. De th I I Eastern Surface Seal Installed by Repair Work Done LR'*_'Type of Pump S(Qrn H.P. 3 State-Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 00 Installation will serve: Residence— Commercial— Other f 00 Number of living units: Number of bedrooms P Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota_I length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line CF 1 , SEEPAGE PITS I I Depth Size Number �) SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 applica call for all required inspeco s. Complete drawing on reverse side. Signed , Title: _� 6 1E Date: Z 100' 1FOR EPAIRTIVIENT USE ONLY Application Accepted by Date �"�-c1`��L_ rea _ y� 5—r Pit or rot Inspection bye- Date fr Final Inspection by Date a' Additional Comments: iv ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ENDO MOUNT DUE AMOUNT REMITTED CK 49 CASH RECEIVED BY DATE PERMIT"NO. t EH 13-24 iREV.i/s 51 S �"� EH 14-28 ��c �—�