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C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 w PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. F Job Address lqZb 2- N' AZwe City S7f t� Lot Size Aod k Zya� PM Owner's Name Address Phone 31 0794 ContractorEG VI– Arle-0Z> —:Address os" • &IZ-L n.1 License No. Sdyd`Y7b Phone 5/65=39 71 TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION '❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1fAGRICULTURE WELL OTHER WELL PITS/SUMPS 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 {� ❑ Public ❑ Other ❑ Delta Depth-of_Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth . ❑ Eastern' Surface Seal Installed by State Work Done s _ Repair Work Done ❑ Type of Pump H.P.Well Destruction ❑ Well Diameter Sealing Material (top 601 Depth Filler Material (Below 50'1 v TYPE OF SEPTIC WORK: NEW INSTALLATION El"'REPAIR7ADDITION DESTRUCTION ❑ (No septic.system permitted if public sewer is J „.. available within 200 feef.) Installation will serve: Residence— Commercial! Other ' y C Number of living units: Number of bedrooms i 4 Character of soil to a depth of 3 feet. - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity�, No..'Compartments PKG. TREATMENT PLT. ❑ M Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE YIN,. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well 7.0 Foundation' _'75'0`. 'Property Line SEEPAGE PITS Depth �-S+ Size Number r SUMPS ❑ Distance to nearest: Well i Za Foundation 7 Property Line I DISPOSAL PONDS ❑ 7 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed' - T– Title: Date: FOR DEP E USE ONLY,,! Application Accepted by Date e !:/ Pit or Grout Inspection by Date Final Inspection by 'Date I «r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 t , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 I # , FEE AMOUNT DUE AMOUNT REMITTED ' CASH' RECEIVED BY DATE PERMIT NO. INFO + EH14-28 3-24 1 REV,I/H si EH 1C�7