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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. ` rt ! Job Address `L\ii city+b t Size PM Owner's Name Address J r' Phone Contractor's Name L -L L2W AttT'ttn Cicense No"�`��'✓—� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4Z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .• - -----FOUNDATION_._,_.". , GRICULTURE_W-r=LL--O.THER-WELL___._ �P_LTS/.SUMP-S, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing— .Specifications ❑ Public �,--,�.F,....- ...,,,.......�..m ❑ Irrigation ❑ Other _ �..�. ❑ De Seal Delta r. .-..T ..Pth of Grout Type of Grout �❑ {� \ � ---Approx.. Depth Eastern Surface Seal Installed by� O Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diam" eter Sealing Material (top 501 lir _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION' RUCTION ❑ IN septic system permitted if public sewer is r � � available within 200 feet.) -- =—Installation will serve:_ Residence __ Commercial V Other Number. of living units: Number of bedrooms j Character of soil to a depth of 3 feet:: O Water table depth SEPTIC TANK❑"Type/Mfg, r Capacity 4 No. Compartments PKG. TREATMENT PLT. L7 ..: ? Method of Disposal JO r Distance to nearest: Well .._ Foundation Property Line s ! 7_ LEACHING LINE FILTER BED SEEPAGE PITS SUMPS DISPOSAL PONDS ❑ No. & Length of lines ( Total length/size ❑ Distance to nearest: Well Foundation ( Property Line depth_,_ ❑ Distance to nearest: ❑( Well Foundation r� Number._ Property Line hereby certify that I have prepared-this,applica`tion�and-that the-work�n ill -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- te n laws of California-- The ap t must II a r q ired i cti . Complete drawing on r verse si e t Signe �% Title:, _/ Date: / r� FOR DEPARTMENT USE ONLY j L Application Accepted by •_ a� Date Area 8 Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: f # ❑ Stk 466-6761 ❑ 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 a FEE AMOUNT DUE AMOUNT REMITTED CK # ` e INFO CASH RECEIVED By DATE PERMIT'NO. + EH 1329 (REV. 10/831 EH -14-26 -