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f' APPLICATION FOR PERMIT .:, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Rules and Regulations i the San Joaquin Local Health District. ,. City_ Lot Size PM Job Address + y = Phone Owner's Name — �— 0" Address — y Contractor '" q� Address { S` fit' ' 01 License No. Z- Fhon TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR fl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK• SEWER LINES DISPOSACFLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA r'dCONSTRUCTION SPECIFICATIONS Dia, of-Well Casing ❑ Industrial—. �,7 ❑Apen Bottom ❑ Manteca Dia. of Well Excavation C Type of Casing— Domestic asing Specifications ❑ Domestic/Private :3 .Gravel Pack ❑ Tracy Type of Grout ❑ Public i- Y•�� ❑1Other-_99 r ❑ Delta --- Depth of Grout Seal _ - - ❑ Irrigation � �Approx. Depth ❑ Eastern Surface Seal Installed by ' .y _ . State'Work Done "", ti Repair Work bone ❑ Type of Pump H.P. +, x, Sealing Material )top 50'1 Well Destruction- El Well Diameter + Z Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ 11 avlailab elwith ne200 feetitted if public sewer is ` 1 pp I � : Installation will serve: Residence Commercial ZOther �, ) l" "y ( Number'of living units: Number of bedrooms �,--I f f Water table dept4i Character of soil to a depth of 3 feet: A 1 a 6 No.�Compartments G SEPTIC TANK ®/rtypelMfg apacity� 1 Y,; Method'of Dirsposal PKG. TREATMENT PLT. ❑ �{}f Property tine Distance to nearest: Well��-- Foundation ; � Foundation T tal lengthlsize LEACHING LINE C�No. & Length of lines r• ❑ Distance to nearest: Well— -? Property Line — FILTER BED Number r SEEPAGE PITS Depth Size t t} SUMPS �. El Distance to nearest: Well 136 Foundation� Property Line. I DISPOSAL PONDS: ❑ hereby certify that 1-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, l signature shall not ` of employ any person in such manneras n the performance of the work foswh ccomh this permit tion vis issuedlfl shall II employ pesorls(s!ubjec#tong or. bworkmanls compensa I certifies the following:"I certify thatpe ' tion laws of California." The applicant must call Jqj all ykquired inspections..Complete drawing on reverse side. IDabi Signed Title: — �, ,• i FOR DEPARTMENT USE'ONLY � a. 1 1 ' Date . . n read Application ccepted by �(� �'E.[�4.1 t? rte.�,�r e pe n !�r�,� + ate ^0 In3 ,Final Inspectio by v Pit or o t s d3160 tzril ° Q ' Additional Comments: (� + .tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 i❑ cy 835 6385 w. v tfi PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 952 01 Applicant- Return all copies to: Environmental Heal oa �!� FCK S RECEIVED BY DATE PERMIT�NO. EE ,h= AMOUNT DUE AMOUNT REMITTED CASH "y INFO + EH 13-24(REV.1/a EH 14.28 111