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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZEL i ON AVE.; STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEARFROM DATE ISSUED p' (Complete in triplicate) S - 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 Joaquiri,County,Ordinance No.549 for sewage or No.ItQ for well/pump and the Rules and Regulations of the San Joaquin Local Health District: t.„ ' 'mak,/-• I ,fob Address /� . iC=f,t7Gyt� �C�� city- _ ZZ_i36 I ._ nLot Size � PM Owner's Name Address _ LL7�1��/ 1"la�/} &GeQ,Phone I 7- Contractor h>�'!C-1LLlC 4�. Addresselmya& tiC icense No. o�9D 8>!.J Phone �l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E3- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /00 SEWER LINES DISPOSAL FLD. i .� PROP. LINE C1� FOUNDATION AGRICULTURE WELL OTHER WELL--PITSkSU.MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom r, p ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X DomesticlPriva4 ISI Gravel Pack ❑.Tracy Type of Casing-- p_VC,__ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal — Type of Gr t k q Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r i Well Destruction ❑ Well Diameter Sealing Material (top 50') 20 i Depth e�-�[�„ 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. ❑ 1 a -. Method of Disposal Distance to nearest: Well Foundation Property Line .I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Di'stanc'e to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth; Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS ❑. . #may, I 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 tri the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Ca ornia." ;1. The a ust call for all re 'ad inspec ions. Comple a reverse side. Signed Thl Date: `7 FOR DEPA MENT USE ONLY Applicatio cepted by ' Date � � �� Ax A 4T r Pit o Grout spection by Date �� Final Inspection by R Date l Ad '' al Comments: SEP 1�i t ❑ Stk 466-6781 ❑ Lodi 369-3&21 ❑ 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 SW RONMENTAL HEALTH 1�1Y PERMITISERVICES FES)NFO AMOUNT DUEJ AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. CASH { tEH13-24(REV.1ia5) EH 14-28 �. r