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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Completeiin Triplicate) 7 Application is hereby trade 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. 0 00 Job Address City � a� ® Lot Size ,[�0 pM Owner's Name /[`�U�� A Address /��a �� ` Phone Contractor Address .5lO /��7 f/��/��.__ 7�1 3 +�� License No. Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,,❑._ C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 2 4SELINES DISPOSAL FLD. PROP. LINE FOUNDATION AG . . ,-TURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �!) ❑ Industrial ❑ Open Bottom . -❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack, Tracy Type of Casing Specifications ; I ❑ Public ED-Other `r D Deltati � Depth of Grout Seal Type of Grout ❑ Irrigationf;rC —App�rox. Depth p4Easte�n yYy�, 5urfaee:§eal;nstallecl by Y ih" E Repair Worr-D e d State Work Done Type of Pump H.P. Well Destruc r 1�1(elt-p_iamet A` Sealing Material [top 501 Depth P Filler Material {gelow 50')• E�Oa SEPTIC WORK:' NEW INSTALLATION ❑ fREPAFR/ADDITJON- —DfSTRUCT1flN ❑NNa_septic system permitted if put5Gc sewer is_ r, y- ayai�lahI within SOU feet.) Installation will serve: Res Bence Commercial Other b Number of living units: ......:r— Num er of bedrooms, Character of soil to a depth of 3 feet: f' ; M.6ter table depth 1 SEPTIC TANK ❑ Type/Mfgr) � —Ca ty �'e� } /o;Compartment s PKG. TREATMENT PLT. ❑ 4 f#� Method of Disposal Distance$to�riearest _ .Wel oundatiotn Property Line � f LEACHING LINE o. & Length of lines Total length/size i FILTER BED ❑ Distance to nea'r,Wr Well .01d� r Foundation Property Line i SEEPAGE PITSDepth Size �� NumberI�_ f SUMPS ❑ Distance to nearest:. Well ISO 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 ordinance, 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 work�n an's compensa- tion laws of California." The appli ust call for affjeqi4firecl ins ections. Complete drawing on reverse side. # Signed X Title: Date: s � FOR DEPARTMENT USE ONLY Application Accepted by Date 7,--?,6 Area / it or Grout Inspection by Date �O Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 uF Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.I/R5) EH 1428