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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Ryles and Regulations of the San Joaquin Local Health District. p ' Job Address 2!-7 City Sot Size PM e-00"T-y f'i4Q1C54- 4 -3 Owner's Name 51AAI OA 121/J W-T/,!¢dress Phone C,Q�bfai Jo1. .sPo�erS GOf-rpt. . Contractor 3 ddress 711- L-C b License No. 6�81�--Phone TYPE OF WELL/PUMP: NEW WELL LJ _ WELL REPLACEMENT ❑, ,� DESTRUCTION LJ PUMP INSTALLATION k7 SYSTEM REPAIR ❑ r OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 27 DISPOSAL FLO. PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,14 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. A�) State Work Done IR5 7'62-4- Well Destruction ❑. Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:—NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ' Foundation Property Line LEACHING LINE _❑,- No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line, SEEPAGE PITS ❑ Depth Size Number SUMP'S If 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 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 rrianner 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 Idws of California." The applicant m fc all re' 'r inspections. Complete drawing on reverse 1de. Signed Xs Title:-JL%`" ��7 Date: S� FOR DEPARTMENT USE ONLY r Application Acc pted by _ Date �� Q Area Pit or Grout Inspection by Date Final Inspection-by Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369 3621 I'] Manteca 823-71D4 C3 Tracy 835-6385 ` I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201" R FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO EH 13.24(REV.7/e sl t�"J[ � > �S �•1� S EH 14-26 I C00/v?y