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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , . 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209).466-6* 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. !!" �i Y;' * - Job Address � �Lt„ �~['' CityFA C —''Lot SiL:779x 114PM Owner's Namef!� r� >L'1 f"a -Address r__.�� C�VLA— .1C.\k -. . Phone. �. f i Contractor` "—Addres's' License TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Er l I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ fes, OTHER"❑-j'• r DISTANCE TO NEAREST: SEPTIC TANK� SEWER LINES DISPOSAL'FLD. - PROP. LINE _ 1 FOUNDATION AGRICULTURE WELL OTHER-WELL—, PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .', 14 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation :Dia. of Well Casing tKQomestic/Private ❑ Gravel Paci ❑ Tracy Type of Casing (Specifications ❑ Public: ElOther t 1-1Delta Depth of Grout Seal %' 'Type of Grout t � ❑ Irri atioh- �A rox. Depth ❑ Eastern Surface Seal Installed b '? W 9 pp P Y Repair Work Done ❑ Type of Pump H.P. State Work Done% 2 i ti W Well Destruction ❑ Well Diameter. Sealing Material [top 501 t i I �.'c`\ Depth 30 Filler Material (Below 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) i Installation will serve: Residence� Commercial_ 'Other i Number of living units: - :Number of bedrooms ' { Character of soil to a depth of 3 feet: (AS k ` p water table depth SEPTIC TANK ❑ Type/Mfgd(}.W,i_._ 17MI05Q✓ Capacity12 ..�..., No.lCompartments 2 % y. PKG. TREATMENT PLT. ❑ �Metfiod of Dis�osal Distance to nearest: Well Foundation -Pr(T erty Liner f r LEACHING LINE Vo. & Length of lines S Total length/size 7 f FILTER BED ❑ Distance to nearest: Welt Foundation _Pro ReCine SEEPAGE PITS ❑ D_epth-- " Size Number SUMPS Property❑ Distance to nearest: Well Foundation Prop a Line DISPOSAL PONDS ❑ , , € hereby certify that I have prepared this ap�licaiion`'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."Contractoi'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 appl'ca must call f r required inspections. Complete drawing on reverse side. Signed A I K & Title: Date, _. OR DEPARTMENT USE ONLY � t Application Accepted by Date r Pit or Grout Inspection by Date Final Inspection by to Additional Comments:__ _ I' ❑ 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 f r 'FEET AMOUNT'DUE _ AMOUNT REMITTED f CK#' pEt EIVED 8Y" -DATE PERMIT"N0. { INFO .+ EH 13-24(REV.I/a 8) EH 14-26 �-